TY - JOUR AU - Wu, Yiqun AU - Chen, Fei AU - Song, Haiqing AU - Feng, Wuwei AU - Sun, Jinping AU - Liu, Ruisen AU - Li, Dongmei AU - Liu, Ying PY - 2021/2/9 TI - Use of a Smartphone Platform to Help With Emergency Management of Acute Ischemic Stroke: Observational Study JO - JMIR Mhealth Uhealth SP - e25488 VL - 9 IS - 2 KW - acute ischemic stroke KW - door-to-needle time KW - smartphone platform KW - emergency management KW - smartphone KW - mHealth KW - stroke KW - management KW - emergency KW - first aid KW - utility KW - digital health N2 - Background: To improve the outcomes of acute ischemic stroke (AIS), timely thrombolytic therapy is crucial. Series strategies were recommended to reduce door-to-needle (DTN) time for AIS. Mobile technologies are feasible and have been used in stroke management for various purposes. However, the use of smartphone platforms that integrate series strategies through the entire first aid process to improve emergency management of AIS remains to be verified. Objective: This study aims to describe the utility and application of a smartphone platform in the emergency management of AIS and report the DTN time for patients with AIS during its 2-year application period. Our results are relevant to digital health management. Methods: A smartphone platform named ?Green? was developed to incorporate the field assessment, hospital recommendation, prehospital notification, real-time communication, clinical records creation, key time-stamping, and quality control to streamline and standardize overall AIS emergency management processes. The emergency medical system (EMS) and all the emergency departments in Beijing have used this platform since 2018. From January 1, 2018, to December 31, 2019, 8457 patients diagnosed with AIS received intravenous tissue-type plasminogen activator therapy. The median DTN time and the proportions of patients with DTN times of ?60 minutes and ?45 minutes were reported. Results: During the 2-year application period of this platform, the median DTN time was 45 minutes, and the proportions of patients with DTN times of ?60 minutes and ?45 minutes were 74.6% and 50.5%, respectively. The median DTN time was significantly reduced from 50 minutes in 2018 to 42 minutes in 2019 (P<.001). The proportions of patients with DTN times of ?60 minutes and ?45 minutes increased from 66.1% and 40.7%, respectively, in 2018 to 80.7% and 57.3%, respectively, in 2019 (both P<.001). Sustained improvement in DTN time was seen during all the observed months. The improvement occurred across all facilities, and the variations among hospitals also decreased. The median DTN time for patients transferred by ambulances (43 minutes) was significantly shorter than those who reached hospitals by themselves (47 minutes; P<.001). Conclusions: Sustained reductions in DTN time reflected the improvement in AIS emergency management processes. The use of a smartphone platform integrating recommended strategies throughout all first aid stages is a practical way to help the emergency management of AIS. UR - http://mhealth.jmir.org/2021/2/e25488/ UR - http://dx.doi.org/10.2196/25488 UR - http://www.ncbi.nlm.nih.gov/pubmed/33560236 ID - info:doi/10.2196/25488 ER - TY - JOUR AU - Stengl, Helena AU - Ganeshan, Ramanan AU - Hellwig, Simon AU - Blaszczyk, Edyta AU - Fiebach, B. Jochen AU - Nolte, H. Christian AU - Bauer, Axel AU - Schulz-Menger, Jeanette AU - Endres, Matthias AU - Scheitz, F. Jan PY - 2021/2/5 TI - Cardiomyocyte Injury Following Acute Ischemic Stroke: Protocol for a Prospective Observational Cohort Study JO - JMIR Res Protoc SP - e24186 VL - 10 IS - 2 KW - ischemic stroke KW - troponin T KW - myocardial ischemia KW - myocardial injury KW - stroke-heart syndrome KW - cardiac imaging techniques KW - magnetic resonance imaging KW - Takotsubo syndrome KW - autonomic nervous system N2 - Background: Elevated cardiac troponin, which indicates cardiomyocyte injury, is common after acute ischemic stroke and is associated with poor functional outcome. Myocardial injury is part of a broad spectrum of cardiac complications that may occur after acute ischemic stroke. Previous studies have shown that in most patients, the underlying mechanism of stroke-associated myocardial injury may not be a concomitant acute coronary syndrome. Evidence from animal research and clinical and neuroimaging studies suggest that functional and structural alterations in the central autonomic network leading to stress-mediated neurocardiogenic injury may be a key underlying mechanism (ie, stroke-heart syndrome). However, the exact pathophysiological cascade remains unclear, and the diagnostic and therapeutic implications are unknown. Objective: The aim of this CORONA-IS (Cardiomyocyte injury following Acute Ischemic Stroke) study is to quantify autonomic dysfunction and to decipher downstream cardiac mechanisms leading to myocardial injury after acute ischemic stroke. Methods: In this prospective, observational, single-center cohort study, 300 patients with acute ischemic stroke, confirmed via cerebral magnetic resonance imaging (MRI) and presenting within 48 hours of symptom onset, will be recruited during in-hospital stay. On the basis of high-sensitivity cardiac troponin levels and corresponding to the fourth universal definition of myocardial infarction, 3 groups are defined (ie, no myocardial injury [no cardiac troponin elevation], chronic myocardial injury [stable elevation], and acute myocardial injury [dynamic rise/fall pattern]). Each group will include approximately 100 patients. Study patients will receive routine diagnostic care. In addition, they will receive 3 Tesla cardiovascular MRI and transthoracic echocardiography within 5 days of symptom onset to provide myocardial tissue characterization and assess cardiac function, 20-min high-resolution electrocardiogram for analysis of cardiac autonomic function, and extensive biobanking. A follow-up for cardiovascular events will be conducted 3 and 12 months after inclusion. Results: After a 4-month pilot phase, recruitment began in April 2019. We estimate a recruitment period of approximately 3 years to include 300 patients with a complete cardiovascular MRI protocol. Conclusions: Stroke-associated myocardial injury is a common and relevant complication. Our study has the potential to provide a better mechanistic understanding of heart and brain interactions in the setting of acute stroke. Thus, it is essential to develop algorithms for recognizing patients at risk and to refine diagnostic and therapeutic procedures. Trial Registration: Clinicaltrials.gov NCT03892226; https://www.clinicaltrials.gov/ct2/show/NCT03892226. International Registered Report Identifier (IRRID): DERR1-10.2196/24186 UR - http://www.researchprotocols.org/2021/2/e24186/ UR - http://dx.doi.org/10.2196/24186 UR - http://www.ncbi.nlm.nih.gov/pubmed/33544087 ID - info:doi/10.2196/24186 ER - TY - JOUR AU - Marsden, Lesley Dianne AU - Boyle, Kerry AU - Jordan, Louise-Anne AU - Dunne, Anne Judith AU - Shipp, Jodi AU - Minett, Fiona AU - Styles, Amanda AU - Birnie, Jaclyn AU - Ormond, Sally AU - Parrey, Kim AU - Buzio, Amanda AU - Lever, Sandra AU - Paul, Michelle AU - Hill, Kelvin AU - Pollack, P. Michael R. AU - Wiggers, John AU - Oldmeadow, Christopher AU - Cadilhac, Ann-Michele Dominique AU - Duff, Jed AU - PY - 2021/2/4 TI - Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study JO - JMIR Res Protoc SP - e22902 VL - 10 IS - 2 KW - urinary incontinence KW - lower urinary tract symptoms KW - inpatient KW - practice-gap KW - practice improvement KW - protocol N2 - Background: Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care. Objective: This study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards. Methods: This is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47% metropolitan, 8/15, 53% regional) in Australia. Data will be collected at 3 time points: before implementation (T0), immediately after the 6-month implementation period (T1), and again after a 6-month maintenance period (T2). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined. Results: This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T0) was completed in March 2020. As of November 2020, 87% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T1). Conclusions: Our practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package. International Registered Report Identifier (IRRID): DERR1-10.2196/22902 UR - https://www.researchprotocols.org/2021/2/e22902 UR - http://dx.doi.org/10.2196/22902 UR - http://www.ncbi.nlm.nih.gov/pubmed/33538703 ID - info:doi/10.2196/22902 ER - TY - JOUR AU - Katzan, Irene AU - Schuster, Andrew AU - Kinzy, Tyler PY - 2021/1/19 TI - Physical Activity Monitoring Using a Fitbit Device in Ischemic Stroke Patients: Prospective Cohort Feasibility Study JO - JMIR Mhealth Uhealth SP - e14494 VL - 9 IS - 1 KW - physical activity KW - accelerometer KW - ischemic stroke KW - step activity monitor N2 - Background: Continuous tracking of ambulatory activity in real-world settings using step activity monitors has many potential uses. However, feasibility, accuracy, and correlation with performance measures in stroke patients have not been well-established. Objective: The primary study objective was to determine adherence with wearing a consumer-grade step activity monitor, the Fitbit Charge HR, in home-going ischemic stroke patients during the first 90 days after hospital discharge. Secondary objectives were to (1) determine accuracy of step counts of the Fitbit Charge HR compared with a manual tally; (2) calculate correlations between the Fitbit step counts and the mobility performance scores at discharge and 30 days after stroke; (3) determine variability and change in weekly step counts over 90 days; and (4) evaluate patient experience with using the Fitbit Charge HR poststroke. Methods: A total of 15 participants with recent mild ischemic stroke wore a Fitbit Charge HR for 90 days after discharge and completed 3 mobility performance tests from the National Institutes of Health Toolbox at discharge and Day 30: (1) Standing Balance Test, (2) 2-Minute Walk Endurance Test, and (3) 4-Meter Walk Gait Speed Test. Accuracy of step activity monitors was assessed by calculating differences in steps recorded on the step activity monitor and a manual tally during 2-minute walk tests. Results: Participants had a mean age of 54 years and a median modified Rankin scale score of 1. Mean daily adherence with step activity monitor use was 83.6%. Mean daily step count in the first week after discharge was 4376. Daily step counts increased slightly during the first 30 days after discharge (average increase of 52.5 steps/day; 95% CI 32.2-71.8) and remained stable during the 30-90 day period after discharge. Mean step count difference between step activity monitor and manual tally was ?4.8 steps (?1.8%). Intraclass correlation coefficients for step counts and 2-minute walk, standing balance, and 4-meter gait speed at discharge were 0.41 (95% CI ?0.14 to 0.75), ?0.12 (95% CI ?0.67 to 0.64), and 0.17 (95% CI ?0.46 to 0.66), respectively. Values were similarly poor at 30 days. Conclusions: The use of consumer-grade Fitbit Charge HR in patients with recent mild stroke is feasible with reasonable adherence and accuracy. There was poor correlation between step counts and gait speed, balance, and endurance. Further research is needed to evaluate the association between step counts and other outcomes relevant to patients, including patient-reported outcomes and measures of physical function. UR - http://mhealth.jmir.org/2021/1/e14494/ UR - http://dx.doi.org/10.2196/14494 UR - http://www.ncbi.nlm.nih.gov/pubmed/33464213 ID - info:doi/10.2196/14494 ER - TY - JOUR AU - Ranta, Annemarei AU - Thompson, Stephanie AU - Harwood, Ngarongoa Matire Louise AU - Cadilhac, Ann-Michele Dominique AU - Barber, Alan Peter AU - Davis, John Alan AU - Gommans, Henry John AU - Fink, Newton John AU - McNaughton, Karel Harry AU - Denison, Hayley AU - Corbin, Marine AU - Feigin, Valery AU - Abernethy, Virginia AU - Levack, William AU - Douwes, Jeroen AU - Girvan, Jacqueline AU - Wilson, Andrew PY - 2021/1/12 TI - Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care): Protocol for a Nationwide Observational Study JO - JMIR Res Protoc SP - e25374 VL - 10 IS - 1 KW - stroke KW - protocols KW - stroke units KW - rehabilitation KW - M?ori KW - Pacific people KW - health inequities KW - cost-efficacy KW - rural KW - observational study N2 - Background: Stroke systems of care differ between larger urban and smaller rural settings and it is unclear to what extent this may impact on patient outcomes. Ethnicity influences stroke risk factors and care delivery as well as patient outcomes in nonstroke settings. Little is known about the impact of ethnicity on poststroke care, especially in M?ori and Pacific populations. Objective: Our goal is to describe the protocol for the Reducing Ethnic and Geographic Inequities to Optimise New Zealand Stroke Care (REGIONS Care) study. Methods: This large, nationwide observational study assesses the impact of rurality and ethnicity on best practice stroke care access and outcomes involving all 28 New Zealand hospitals caring for stroke patients, by capturing every stroke patient admitted to hospital during the 2017-2018 study period. In addition, it explores current access barriers through consumer focus groups and consumer, carer, clinician, manager, and policy-maker surveys. It also assesses the economic impact of care provided at different types of hospitals and to patients of different ethnicities and explores the cost-efficacy of individual interventions and care bundles. Finally, it compares manual data collection to routine health administrative data and explores the feasibility of developing outcome models using only administrative data and the cost-efficacy of using additional manually collected registry data. Regarding sample size estimates, in Part 1, Study A, 2400 participants are needed to identify a 10% difference between up to four geographic subgroups at 90% power with an ? value of .05 and 10% to 20% loss to follow-up. In Part 1, Study B, a sample of 7645 participants was expected to include an estimated 850 M?ori and 419 Pacific patients and to provide over 90% and over 80% power, respectively. Regarding Part 2, 50% of the patient or carer surveys, 40 provider surveys, and 10 focus groups were needed to achieve saturation of themes. The main outcome is the modified Rankin Scale (mRS) score at 3 months. Secondary outcomes include mRS scores; EQ-5D-3L (5-dimension, 3-level EuroQol questionnaire) scores; stroke recurrence; vascular events; death; readmission at 3, 6, and 12 months; cost of care; and themes around access barriers. Results: The study is underway, with national and institutional ethics approvals in place. A total of 2379 patients have been recruited for Part 1, Study A; 6837 patients have been recruited for Part 1, Study B; 10 focus groups have been conducted and 70 surveys have been completed in Part 2. Data collection has essentially been completed, including follow-up assessment; however, primary and secondary analyses, data linkage, data validation, and health economics analysis are still underway. Conclusions: The methods of this study may provide the basis for future epidemiological studies that will guide care improvements in other countries and populations. International Registered Report Identifier (IRRID): DERR1-10.2196/25374 UR - https://www.researchprotocols.org/2021/1/e25374 UR - http://dx.doi.org/10.2196/25374 UR - http://www.ncbi.nlm.nih.gov/pubmed/33433396 ID - info:doi/10.2196/25374 ER - TY - JOUR AU - Georgiou, Theodoros AU - Holland, Simon AU - van der Linden, Janet PY - 2020/11/24 TI - Rhythmic Haptic Cueing for Gait Rehabilitation of People With Hemiparesis: Quantitative Gait Study JO - JMIR Biomed Eng SP - e18649 VL - 5 IS - 1 KW - hemiparetic gait KW - stroke KW - technology assisted rehabilitation KW - quantitative study KW - gait analysis KW - gait asymmetry KW - gait KW - neurology KW - hemiparesis KW - rehabilitation KW - brain injury N2 - Background: Rhythm, brain, and body are closely linked. Humans can synchronize their movement to auditory rhythms in ways that can improve the regularity of movement while reducing perceived effort. However, the ability to perform rhythmic movement may be disrupted by various neurological conditions. Many such conditions impair mechanisms that control movement, such as gait, but typically without rhythmic perception being affected. This paper focuses on hemiparetic stroke, a neurological condition that affects one side of the body. Hemiparetic stroke can cause severe asymmetries in gait, leading to numerous physical problems ranging from muscle degeneration to bone fractures. Movement synchronization via entrainment to auditory metronomes is known to improve asymmetry and related gait problems; this paper presents the first systematic study of entrainment for gait rehabilitation via the haptic modality. Objective: This paper explores the gait rehabilitation of people with hemiparesis following a stroke or brain injury, by a process of haptic entrainment to rhythmic cues. Various objective measures, such as stride length and stride time, are considered. Methods: This study is a quantitative gait study combining temporal and spatial data on haptically cued participants with hemiparetic stroke and brain injury. We designed wearable devices to deliver the haptic rhythm, called Haptic Bracelets, which were placed on the leg near the knee. Spatial data were recorded using a Qualisys optical motion capturing system, consisting of 8 optoelectronic cameras, and 20 markers placed on anatomical lower limb landmarks and 4 additional tracking clusters placed on the right and left shank and thigh. Gait characteristics were measured before, during, and after cueing. Results: All 11 successfully screened participants were able to synchronize their steps to a haptically presented rhythm. Specifically, 6 participants demonstrated immediate improvements regarding their temporal gait characteristics, and 3 of the 6 improved their gait in terms of spatial characteristics. Conclusions: Considering the great variability between survivors of stroke and brain injury and the limited number of available participants in our study, there is no claim of statistical evidence that supports a formal experimental result of improved gait. However, viewing this empirical gait investigation as a set of 11 case studies, more modest empirical claims can be made. All participants were able to synchronize their steps to a haptically presented rhythm. For a substantial proportion of participants, an immediate (though not necessarily lasting) improvement of temporal gait characteristics was found during cueing. Some improvements over baseline occurred immediately after, rather than during, haptic cueing. Design issues and trade-offs are identified, and interactions between perception, sensory deficit, attention, memory, cognitive load, and haptic entrainment are noted. UR - http://biomedeng.jmir.org/2020/1/e18649/ UR - http://dx.doi.org/10.2196/18649 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/18649 ER - TY - JOUR AU - LeLaurin, H. Jennifer AU - Lamba, H. Avi AU - Eliazar-Macke, D. Nathaniel AU - Schmitzberger, K. Magda AU - Freytes, Magaly I. AU - Dang, Stuti AU - Vogel, Bruce W. AU - Levy, E. Charles AU - Klanchar, Angelina S. AU - Beyth, J. Rebecca AU - Shorr, I. Ronald AU - Uphold, R. Constance PY - 2020/11/11 TI - Postdischarge Intervention for Stroke Caregivers: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e21799 VL - 9 IS - 11 KW - COVID-19 KW - stroke KW - caregivers KW - depression KW - burden KW - randomized controlled trial KW - web-based intervention KW - problem-solving N2 - Background: The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. Objective: The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient?s transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. Methods: The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers? Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers? burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors? functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. Results: Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. Conclusions: This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. Trial Registration: ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131 International Registered Report Identifier (IRRID): DERR1-10.2196/21799 UR - http://www.researchprotocols.org/2020/11/e21799/ UR - http://dx.doi.org/10.2196/21799 UR - http://www.ncbi.nlm.nih.gov/pubmed/33174856 ID - info:doi/10.2196/21799 ER - TY - JOUR AU - Dunne, Stephen AU - Close, Helen AU - Richards, Nicola AU - Ellison, Amanda AU - Lane, R. Alison PY - 2020/10/23 TI - Maximizing Telerehabilitation for Patients With Visual Loss After Stroke: Interview and Focus Group Study With Stroke Survivors, Carers, and Occupational Therapists JO - J Med Internet Res SP - e19604 VL - 22 IS - 10 KW - telerehabilitation KW - vision KW - barriers KW - facilitators KW - technology N2 - Background: Visual field defects are a common consequence of stroke, and compensatory eye movement strategies have been identified as the most promising rehabilitation option. There has been a move toward compensatory telerehabilitation options, such as the Durham Reading and Exploration (DREX) training app, which significantly improves visual exploration, reading, and self-reported quality of life. Objective: This study details an iterative process of liaising with stroke survivors, carers, and health care professionals to identify barriers and facilitators to using rehabilitation tools, as well as elements of good practice in telerehabilitation, with a focus on how the DREX package can be maximized. Methods: Survey data from 75 stroke survivors informed 12 semistructured engagement activities (7 focus groups and 5 interviews) with 32 stroke survivors, 10 carers, and 24 occupational therapists. Results: Thematic analysis identified key themes within the data. Themes identified problems associated with poststroke health care from both patients? and occupational therapists? perspectives that need to be addressed to improve uptake of this rehabilitation tool and telerehabilitation options generally. This included identifying additional materials or assistance that were required to boost the impact of training packages. The acute rehabilitation setting was an identified barrier, and perceptions of technology were considered a barrier by some but a facilitator by others. In addition, 4 key features of telerehabilitation were identified: additional materials, the importance of goal setting, repetition, and feedback. Conclusions: The data were used to try to overcome some barriers to the DREX training and are further discussed as considerations for telerehabilitation in general moving forward. UR - http://www.jmir.org/2020/10/e19604/ UR - http://dx.doi.org/10.2196/19604 UR - http://www.ncbi.nlm.nih.gov/pubmed/33095179 ID - info:doi/10.2196/19604 ER - TY - JOUR AU - Giebel, D. Godwin PY - 2020/10/6 TI - Use of mHealth Devices to Screen for Atrial Fibrillation: Cost-Effectiveness Analysis JO - JMIR Mhealth Uhealth SP - e20496 VL - 8 IS - 10 KW - mHealth KW - atrial fibrillation KW - screening devices KW - strokes KW - cost-effectiveness KW - photoplethysmography N2 - Background: With an estimated prevalence of around 3% and an about 2.5-fold increased risk of stroke, atrial fibrillation (AF) is a serious threat for patients and a high economic burden for health care systems all over the world. Patients with AF could benefit from screening through mobile health (mHealth) devices. Thus, an early diagnosis is possible with mHealth devices, and the risk for stroke can be markedly reduced by using anticoagulation therapy. Objective: The aim of this work was to assess the cost-effectiveness of algorithm-based screening for AF with the aid of photoplethysmography wrist-worn mHealth devices. Even if prevented strokes and prevented deaths from stroke are the most relevant patient outcomes, direct costs were defined as the primary outcome. Methods: A Monte Carlo simulation was conducted based on a developed state-transition model; 30,000 patients for each CHA2DS2-VASc (Congestive heart failure, Hypertension, Age?75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category [female]) score from 1 to 9 were simulated. The first simulation served to estimate the economic burden of AF without the use of mHealth devices. The second simulation served to simulate the economic burden of AF with the use of mHealth devices. Afterwards, the groups were compared in terms of costs, prevented strokes, and deaths from strokes. Results: The CHA2DS2-VASc score as well as the electrocardiography (ECG) confirmation rate had the biggest impact on costs as well as number of strokes. The higher the risk score, the lower were the costs per prevented stroke. Higher ECG confirmation rates intensified this effect. The effect was not seen in groups with lower risk scores. Over 10 years, the use of mHealth (assuming a 75% ECG confirmation rate) resulted in additional costs (?1=US $1.12) of ?441, ?567, ?536, ?520, ?606, ?625, ?623, ?692, and ?847 per patient for a CHA2DS2-VASc score of 1 to 9, respectively. The number of prevented strokes tended to be higher in groups with high risk for stroke. Higher ECG confirmation rates led to higher numbers of prevented strokes. The use of mHealth (assuming a 75% ECG confirmation rate) resulted in 25 (7), ?68 (?54), 98 (?5), 266 (182), 346 (271), 642 (440), 722 (599), 1111 (815), and 1116 (928) prevented strokes (fatal) for CHA2DS2-VASc score of 1 to 9, respectively. Higher device accuracy in terms of sensitivity led to even more prevented fatal strokes. Conclusions: The use of mHealth devices to screen for AF leads to increased costs but also a reduction in the incidence of stroke. In particular, in patients with high CHA2DS2-VASc scores, the risk for stroke and death from stroke can be markedly reduced. UR - http://mhealth.jmir.org/2020/10/e20496/ UR - http://dx.doi.org/10.2196/20496 UR - http://www.ncbi.nlm.nih.gov/pubmed/33021489 ID - info:doi/10.2196/20496 ER - TY - JOUR AU - Park, Eunjeong AU - Lee, Kijeong AU - Han, Taehwa AU - Nam, Suk Hyo PY - 2020/9/16 TI - Automatic Grading of Stroke Symptoms for Rapid Assessment Using Optimized Machine Learning and 4-Limb Kinematics: Clinical Validation Study JO - J Med Internet Res SP - e20641 VL - 22 IS - 9 KW - machine learning KW - artificial intelligence KW - sensors KW - kinematics KW - stroke KW - telemedicine N2 - Background: Subtle abnormal motor signs are indications of serious neurological diseases. Although neurological deficits require fast initiation of treatment in a restricted time, it is difficult for nonspecialists to detect and objectively assess the symptoms. In the clinical environment, diagnoses and decisions are based on clinical grading methods, including the National Institutes of Health Stroke Scale (NIHSS) score or the Medical Research Council (MRC) score, which have been used to measure motor weakness. Objective grading in various environments is necessitated for consistent agreement among patients, caregivers, paramedics, and medical staff to facilitate rapid diagnoses and dispatches to appropriate medical centers. Objective: In this study, we aimed to develop an autonomous grading system for stroke patients. We investigated the feasibility of our new system to assess motor weakness and grade NIHSS and MRC scores of 4 limbs, similar to the clinical examinations performed by medical staff. Methods: We implemented an automatic grading system composed of a measuring unit with wearable sensors and a grading unit with optimized machine learning. Inertial sensors were attached to measure subtle weaknesses caused by paralysis of upper and lower limbs. We collected 60 instances of data with kinematic features of motor disorders from neurological examination and demographic information of stroke patients with NIHSS 0 or 1 and MRC 7, 8, or 9 grades in a stroke unit. Training data with 240 instances were generated using a synthetic minority oversampling technique to complement the imbalanced number of data between classes and low number of training data. We trained 2 representative machine learning algorithms, an ensemble and a support vector machine (SVM), to implement auto-NIHSS and auto-MRC grading. The optimized algorithms performed a 5-fold cross-validation and were searched by Bayes optimization in 30 trials. The trained model was tested with the 60 original hold-out instances for performance evaluation in accuracy, sensitivity, specificity, and area under the receiver operating characteristics curve (AUC). Results: The proposed system can grade NIHSS scores with an accuracy of 83.3% and an AUC of 0.912 using an optimized ensemble algorithm, and it can grade with an accuracy of 80.0% and an AUC of 0.860 using an optimized SVM algorithm. The auto-MRC grading achieved an accuracy of 76.7% and a mean AUC of 0.870 in SVM classification and an accuracy of 78.3% and a mean AUC of 0.877 in ensemble classification. Conclusions: The automatic grading system quantifies proximal weakness in real time and assesses symptoms through automatic grading. The pilot outcomes demonstrated the feasibility of remote monitoring of motor weakness caused by stroke. The system can facilitate consistent grading with instant assessment and expedite dispatches to appropriate hospitals and treatment initiation by sharing auto-MRC and auto-NIHSS scores between prehospital and hospital responses as an objective observation. UR - http://www.jmir.org/2020/9/e20641/ UR - http://dx.doi.org/10.2196/20641 UR - http://www.ncbi.nlm.nih.gov/pubmed/32936079 ID - info:doi/10.2196/20641 ER - TY - JOUR AU - Seo, Minseok AU - Shin, Myung-Jun AU - Park, Sung Tae AU - Park, Jong-Hwan PY - 2020/9/10 TI - Clinometric Gait Analysis Using Smart Insoles in Patients With Hemiplegia After Stroke: Pilot Study JO - JMIR Mhealth Uhealth SP - e22208 VL - 8 IS - 9 KW - stroke KW - hemiplegia KW - gait KW - smart insole KW - medical informatics KW - rehabilitation KW - observational KW - wearable KW - assessment N2 - Background: For effective rehabilitation after stroke, it is essential to conduct an objective assessment of the patient?s functional status. Several stroke severity scales have been used for this purpose, but such scales have various limitations. Objective: Gait analysis using smart insole technology can be applied continuously, objectively, and quantitatively, thereby overcoming the shortcomings of other assessment tools. Methods: To confirm the reliability of gait analysis using smart insole technology, normal healthy controls wore insoles in their shoes during the Timed Up and Go (TUG) test. The gait parameters were compared with the manually collected data. To determine the gait characteristics of patients with hemiplegia due to stroke, they were asked to wear insoles and take the TUG test; gait parameters were calculated and compared with those of control subjects. To investigate whether the gait analysis accurately reflected the patients? clinical condition, we analyzed the relationships of 22 gait parameters on 4 stroke severity scales. Results: The smart insole gait parameter data were similar to those calculated manually. Among the 18 gait parameters tested, 14 were significantly effective at distinguishing patients from healthy controls. The smart insole data revealed that the stance duration on both sides was longer in patients than controls, which has proven difficult to show using other methods. Furthermore, the sound side in patients showed a markedly longer stance duration. Regarding swing duration, that of the sound side was shorter in patients than controls, whereas that of the hemiplegic side was longer. We identified 10 significantly correlated gait parameters on the stroke severity scales. Notably, the difference in stance duration between the sound and hemiplegic sides was significantly correlated with the Fugl-Meyer Assessment (FMA) lower extremity score. Conclusions: This study confirmed the feasibility and applicability of the smart insole as a device to assess the gait of patients with hemiplegia due to stroke. In addition, we demonstrated that the FMA score was significantly correlated with the smart insole data. Providing an environment where stroke patients can easily measure walking ability helps to maintain chronic functions as well as acute rehabilitation. Trial Registration: UMIN Clinical Trials Registry UMIN000041646, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047538 UR - http://mhealth.jmir.org/2020/9/e22208/ UR - http://dx.doi.org/10.2196/22208 UR - http://www.ncbi.nlm.nih.gov/pubmed/32909949 ID - info:doi/10.2196/22208 ER - TY - JOUR AU - Minen, Tova Mia AU - Reichel, Frederica Julia AU - Pemmireddy, Pallavi AU - Loder, Elizabeth AU - Torous, John PY - 2020/8/4 TI - Characteristics of Neuropsychiatric Mobile Health Trials: Cross-Sectional Analysis of Studies Registered on ClinicalTrials.gov JO - JMIR Mhealth Uhealth SP - e16180 VL - 8 IS - 8 KW - smartphones KW - mobile phones KW - apps KW - mental health KW - regulation KW - stroke KW - migraine KW - major depressive disorder KW - Alzheimer disease KW - anxiety disorders KW - alcohol use disorders KW - opioid use disorders KW - epilepsy KW - schizophrenia N2 - Background: The development of mobile health (mHealth) technologies is progressing at a faster pace than that of the science to evaluate their validity and efficacy. Under the International Committee of Journal Medical Editors (ICMJE) guidelines, clinical trials that prospectively assign people to interventions should be registered with a database before the initiation of the study. Objective: The aim of this study was to better understand the smartphone mHealth trials for high-burden neuropsychiatric conditions registered on ClinicalTrials.gov through November 2018, including the number, types, and characteristics of the studies being conducted; the frequency and timing of any outcome changes; and the reporting of results. Methods: We conducted a systematic search of ClinicalTrials.gov for the top 10 most disabling neuropsychiatric conditions and prespecified terms related to mHealth. According to the 2016 World Health Organization Global Burden of Disease Study, the top 10 most disabling neuropsychiatric conditions are (1) stroke, (2) migraine, (3) major depressive disorder, (4) Alzheimer disease and other dementias, (5) anxiety disorders, (6) alcohol use disorders, (7) opioid use disorders, (8) epilepsy, (9) schizophrenia, and (10) other mental and substance use disorders. There were no date, location, or status restrictions. Results: Our search identified 135 studies. A total of 28.9% (39/135) of studies evaluated interventions for major depressive disorder, 14.1% (19/135) of studies evaluated interventions for alcohol use disorders, 12.6% (17/135) of studies evaluated interventions for stroke, 11.1% (15/135) of studies evaluated interventions for schizophrenia, 8.1% (11/135) of studies evaluated interventions for anxiety disorders, 8.1% (11/135) of studies evaluated interventions for other mental and substance use disorders, 7.4% (10/135) of studies evaluated interventions for opioid use disorders, 3.7% (5/135) of studies evaluated interventions for Alzheimer disease or other dementias, 3.0% (4/135) of studies evaluated interventions for epilepsy, and 3.0% (4/135) of studies evaluated interventions for migraine. The studies were first registered in 2008; more than half of the studies were registered from 2016 to 2018. A total of 18.5% (25/135) of trials had results reported in some publicly accessible location. Across all the studies, the mean estimated enrollment (reported by the study) was 1078, although the median was only 100. In addition, across all the studies, the actual reported enrollment was lower, with a mean of 249 and a median of 80. Only about a quarter of the studies (35/135, 25.9%) were funded by the National Institutes of Health. Conclusions: Despite the increasing use of health-based technologies, this analysis of ClinicalTrials.gov suggests that only a few apps for high-burden neuropsychiatric conditions are being clinically evaluated in trials. UR - https://mhealth.jmir.org/2020/8/e16180 UR - http://dx.doi.org/10.2196/16180 UR - http://www.ncbi.nlm.nih.gov/pubmed/32749230 ID - info:doi/10.2196/16180 ER - TY - JOUR AU - Signal, June Nada Elizabeth AU - McLaren, Ruth AU - Rashid, Usman AU - Vandal, Alain AU - King, Marcus AU - Almesfer, Faisal AU - Henderson, Jeanette AU - Taylor, Denise PY - 2020/7/29 TI - Haptic Nudges Increase Affected Upper Limb Movement During Inpatient Stroke Rehabilitation: Multiple-Period Randomized Crossover Study JO - JMIR Mhealth Uhealth SP - e17036 VL - 8 IS - 7 KW - stroke KW - rehabilitation KW - physical activity KW - movement KW - disability KW - technology KW - upper limb KW - wearable KW - haptic KW - nudge N2 - Background: As many as 80% of stroke survivors experience upper limb (UL) disability. The strong relationships between disability, lost productivity, and ongoing health care costs mean reducing disability after stroke is critical at both individual and society levels. Unfortunately, the amount of UL-focused rehabilitation received by people with stroke is extremely low. Activity monitoring and promotion using wearable devices offer a potential technology-based solution to address this gap. Commonly, wearable devices are used to deliver a haptic nudge to the wearer with the aim of promoting a particular behavior. However, little is known about the effectiveness of haptic nudging in promoting behaviors in patient populations. Objective: This study aimed to estimate the effect of haptic nudging delivered via a wrist-worn wearable device on UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. Methods: A multiple-period randomized crossover design was used to measure the association of UL movement with the occurrence of haptic nudge reminders to move the affected UL in 20 people with stroke undertaking inpatient rehabilitation. UL movement was observed and classified using movement taxonomy across 72 one-minute observation periods from 7:00 AM to 7:00 PM on a single weekday. On 36 occasions, a haptic nudge to move the affected UL was provided just before the observation period. On the other 36 occasions, no haptic nudge was given. The timing of the haptic nudge was randomized across the observation period for each participant. Statistical analysis was performed using mixed logistic regression. The effect of a haptic nudge was evaluated from the intention-to-treat dataset as the ratio of the odds of affected UL movement during the observation period following a ?Planned Nudge? to the odds of affected limb movement during the observation period following ?No Nudge.? Results: The primary intention-to-treat analysis showed the odds ratio (OR) of affected UL movement following a haptic nudge was 1.44 (95% CI 1.28-1.63, P<.001). The secondary analysis revealed an increased odds of affected UL movement following a Planned Nudge was predominantly due to increased odds of spontaneous affected UL movement (OR 2.03, 95% CI 1.65-2.51, P<.001) rather than affected UL movement in conjunction with unaffected UL movement (OR 1.13, 95% CI 0.99-1.29, P=.07). Conclusions: Haptic nudging delivered via a wrist-worn wearable device increases affected UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. The promoted movement appears to be specific to the instructions given. Trial Registration: Australia New Zealand Clinical Trials Registry 12616000654459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370687&isReview=true UR - https://mhealth.jmir.org/2020/7/e17036 UR - http://dx.doi.org/10.2196/17036 UR - http://www.ncbi.nlm.nih.gov/pubmed/32723718 ID - info:doi/10.2196/17036 ER - TY - JOUR AU - Dimaguila, Luis Gerardo AU - Gray, Kathleen AU - Merolli, Mark PY - 2020/7/28 TI - Enabling Better Use of Person-Generated Health Data in Stroke Rehabilitation Systems: Systematic Development of Design Heuristics JO - J Med Internet Res SP - e17132 VL - 22 IS - 7 KW - person-generated health data KW - patient-reported outcome measures KW - heuristics KW - stroke rehabilitation KW - consumer health informatics KW - evidence-based practice KW - information technology N2 - Background: An established and well-known method for usability assessment of various human-computer interaction technologies is called heuristic evaluation (HE). HE has been adopted for evaluations in a wide variety of specialized contexts and with objectives that go beyond usability. A set of heuristics to evaluate how health information technologies (HITs) incorporate features that enable effective patient use of person-generated health data (PGHD) is needed in an era where there is a growing demand and variety of PGHD-enabled technologies in health care and where a number of remote patient-monitoring technologies do not yet enable patient use of PGHD. Such a set of heuristics would improve the likelihood of positive effects from patients? use of PGHD and lower the risk of negative effects. Objective: This study aims to describe the development of a set of heuristics for the design and evaluation of how well remote patient therapeutic technologies enable patients to use PGHD (PGHD enablement). We used the case of Kinect-based stroke rehabilitation systems (K-SRS) in this study. Methods: The development of a set of heuristics to enable better use of PGHD was primarily guided by the R3C methodology. Closer inspection of the methodology reveals that neither its development nor its application to a case study were described in detail. Thus, where relevant, each step was grounded through best practice activities in the literature and by using Nielsen?s heuristics as a basis for determining the new set of heuristics. As such, this study builds on the R3C methodology, and the implementation of a mixed process is intended to result in a robust and credible set of heuristics. Results: A total of 8 new heuristics for PGHD enablement in K-SRS were created. A systematic and detailed process was applied in each step of heuristic development, which bridged the gaps described earlier. It is hoped that this would aid future developers of specialized heuristics, who could apply the detailed process of heuristic development for other domains of technology, and additionally for the case of PGHD enablement for other health conditions. The R3C methodology was also augmented through the use of qualitative studies with target users and domain experts, and it is intended to result in a robust and credible set of heuristics, before validation and refinement. Conclusions: This study is the first to develop a new set of specialized heuristics to evaluate how HITs incorporate features that enable effective patient use of PGHD, with K-SRS as a key case study. In addition, it is the first to describe how the identification of initial HIT features and concepts to enable PGHD could lead to the development of a specialized set of heuristics. UR - http://www.jmir.org/2020/7/e17132/ UR - http://dx.doi.org/10.2196/17132 UR - http://www.ncbi.nlm.nih.gov/pubmed/32720901 ID - info:doi/10.2196/17132 ER - TY - JOUR AU - Bayona, Hernán AU - Ropero, Brenda AU - Salazar, José Antonio AU - Pérez, Camilo Juan AU - Granja, Felipe Manuel AU - Martínez, Fernando Carlos AU - Useche, Nicolás Juan PY - 2020/7/27 TI - Comprehensive Telestroke Network to Optimize Health Care Delivery for Cerebrovascular Diseases: Algorithm Development JO - J Med Internet Res SP - e18058 VL - 22 IS - 7 KW - stroke KW - telestroke KW - cerebrovascular disease KW - software KW - algorithms KW - emergency medicine KW - clinical pathways N2 - Background: Health care delivery for cerebrovascular diseases is a complex process, which may be improved using telestroke networks. Objective: The purpose of this work was to establish and implement a protocol for the management of patients with acute stroke symptoms according to the available treatment alternatives at the initial point of care and the transfer possibilities. Methods: The review board of our institutions approved this work. The protocol was based on the latest guidelines of the American Heart Association and American Stroke Association. Stroke care requires human and technological resources, which may differ according to the patient?s point of entry into the health care system. Three health care settings were identified to define the appropriate protocols: primary health care setting, intermediate health care setting, and advanced health care setting. Results: A user-friendly web-based telestroke solution was developed. The predictors, scales, and scores implemented in this system allowed the assessment of the vascular insult severity and neurological status of the patient. The total number of possible pathways implemented was as follows: 10 in the primary health care setting, 39 in the intermediate health care setting, and 1162 in the advanced health care setting. Conclusions: The developed comprehensive telestroke platform is the first stage in optimizing health care delivery for patients with stroke symptoms, regardless of the entry point into the emergency network, in both urban and rural regions. This system supports health care personnel by providing adequate inpatient stroke care and facilitating the prompt transfer of patients to a more appropriate health care setting if necessary, especially for patients with acute ischemic stroke within the therapeutic window who are candidates for reperfusion therapies, ultimately contributing to mitigating the mortality and morbidity associated with stroke. UR - http://www.jmir.org/2020/7/e18058/ UR - http://dx.doi.org/10.2196/18058 UR - http://www.ncbi.nlm.nih.gov/pubmed/32716302 ID - info:doi/10.2196/18058 ER - TY - JOUR AU - Langan, Jeanne AU - Bhattacharjya, Sutanuka AU - Subryan, Heamchand AU - Xu, Wenyao AU - Chen, Baicheng AU - Li, Zhengxiong AU - Cavuoto, Lora PY - 2020/7/22 TI - In-Home Rehabilitation Using a Smartphone App Coupled With 3D Printed Functional Objects: Single-Subject Design Study JO - JMIR Mhealth Uhealth SP - e19582 VL - 8 IS - 7 KW - stroke KW - rehabilitation KW - smart technology KW - 3D printing KW - usability N2 - Background: Stroke is a major cause of long-term disability. While there is potential for improvements long after stroke onset, there is little to support functional recovery across the lifespan. mHealth solutions can help fill this gap. mRehab was designed to guide individuals with stroke through a home program and provide performance feedback. Objective: To examine if individuals with chronic stroke can use mRehab at home to improve upper limb mobility. The secondary objective was to examine if changes in limb mobility transferred to standardized clinical assessments. Methods: mRehab consists of a smartphone coupled with 3D printed household items: mug, bowl, key, and doorknob. The smartphone custom app guides task-oriented activities and measures both time to complete an activity and quality of movement (smoothness/accuracy). It also provides performance-based feedback to aid the user in self-monitoring their performance. Task-oriented activities were categorized as (1) object transportation, (2) prehensile grip with supination/pronation, (3) fractionated finger movement, and (4) walking with object. A total of 18 individuals with stroke enrolled in the single-subject experimental design study consisting of pretesting, a 6-week mRehab home program, and posttesting. Pre- and posttesting included both in-laboratory clinical assessments and in-home mRehab recorded samples of task performance. During the home program, mRehab recorded performance data. A System Usability Scale assessed user?s perception of mRehab. Results: A total of 16 participants completed the study and their data are presented in the results. The average days of exercise for each mRehab activity ranged from 15.93 to 21.19 days. This level of adherence was sufficient for improvements in time (t15=2.555, P=.02) and smoothness (t15=3.483, P=.003) in object transportation. Clinical assessments indicated improvements in functional performance (t15=2.675, P=.02) and hand dexterity (t15=2.629, P=.02). Participant?s perception of mRehab was positive. Conclusions: Despite heterogeneity in participants? use of mRehab, there were improvements in upper limb mobility. Smartphone-based portable technology can support home rehabilitation programs in chronic conditions such as stroke. The ability to record performance data from home rehabilitation offers new insights into the impact of home programs on outcomes. Trial Registration: ClinicalTrials.gov NCT04363944; https://clinicaltrials.gov/ct2/show/NCT04363944 UR - http://mhealth.jmir.org/2020/7/e19582/ UR - http://dx.doi.org/10.2196/19582 UR - http://www.ncbi.nlm.nih.gov/pubmed/32706702 ID - info:doi/10.2196/19582 ER - TY - JOUR AU - Bashir, Ayisha PY - 2020/7/17 TI - Stroke and Telerehabilitation: A Brief Communication JO - JMIR Rehabil Assist Technol SP - e18919 VL - 7 IS - 2 KW - telerehabilitation KW - rehabilitation KW - nursing KW - stroke KW - telehealth UR - https://rehab.jmir.org/2020/2/e18919 UR - http://dx.doi.org/10.2196/18919 UR - http://www.ncbi.nlm.nih.gov/pubmed/32706739 ID - info:doi/10.2196/18919 ER - TY - JOUR AU - Appalasamy, Rani Jamuna AU - Joseph, Pauline Joyce AU - Seeta Ramaiah, Siva AU - Md Zain, Zaini Anuar AU - Quek, Fatt Kia AU - Tha, Kyi Kyi PY - 2020/7/10 TI - Video Narratives Intervention Among Stroke Survivors: Feasibility and Acceptability Study of a Randomized Controlled Trial JO - JMIR Aging SP - e17182 VL - 3 IS - 2 KW - feasibility and acceptability KW - medication understanding KW - use self-efficacy KW - stroke KW - video narratives N2 - Background: A large number of stroke survivors worldwide suffer from moderate to severe disability. In Malaysia, long-term uncontrolled stroke risk factors lead to unforeseen rates of recurrent stroke and a growing incidence of stroke occurrence across ages, predominantly among the elderly population. This situation has motivated research efforts focused on tapping into patient education, especially related to patient self-efficacy of understanding and taking medication appropriately. Video narratives integrated with health belief model constructs have demonstrated potential impacts as an aide to patient education efforts. Objective: The aim of this study was to investigate the feasibility and acceptability of study procedures based on a randomized controlled trial protocol of a video narratives intervention among poststroke patients. We also aimed to obtain preliminary findings of video narratives related to medication understanding and use self-efficacy (MUSE) and blood pressure control. Methods: A parallel group randomized controlled trial including a control group (without video viewing) and an intervention group (with video viewing) was conducted by researchers at a neurology outpatient clinic on poststroke patients (N=54). Baseline data included patients? sociodemographic characteristics, medical information, and all outcome measures. Measurements of MUSE and blood pressure following the trial were taken during a 3-month follow-up period. Feasibility of the trial was assessed based on recruitment and study completion rates along with patients? feedback on the burden of the study procedures and outcome measures. Acceptability of the trial was analyzed qualitatively. Statistical analysis was applied to ascertain the preliminary results of video narratives. Results: The recruitment rate was 60 out of 117 patients (51.3%). Nevertheless, the dropout rate of 10% was within the acceptable range. Patients were aged between 21 and 74 years. Nearly 50 of the patients (>85%) had adequate health literacy and exposure to stroke education. Most of the patients (>80%) were diagnosed with ischemic stroke, whereby the majority had primary hypertension. The technicalities of randomization and patient approach were carried out with minimal challenge and adequate patient satisfaction. The video contents received good responses with respect to comprehension and simplicity. Moreover, an in-depth phone interview with 8 patients indicated that the video narratives were considered to be useful and inspiring. These findings paralleled the preliminary findings of significant improvement within groups in MUSE (P=.001) and systolic blood pressure control (P=.04). Conclusions: The queries and feedback from each phase in this study have been acknowledged and will be taken forward in the full trial. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN 12618000174280; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373554 UR - https://aging.jmir.org/2020/2/e17182 UR - http://dx.doi.org/10.2196/17182 UR - http://www.ncbi.nlm.nih.gov/pubmed/32469839 ID - info:doi/10.2196/17182 ER - TY - JOUR AU - Smith, Alexander AU - Bains, Natalie AU - Copeland, Lauren AU - Pennington, Anna AU - Carter, Ben AU - Hewitt, Jonathan PY - 2020/6/17 TI - Morbidity Prevalence Estimate at 6 Months Following a Stroke: Protocol for a Cohort Study JO - JMIR Res Protoc SP - e15851 VL - 9 IS - 6 KW - stroke KW - prevalence estimate KW - morbidity KW - disability KW - PROMs KW - outcomes KW - quality of life (QoL) N2 - Background: Knowledge of the prevalence of morbidity secondary to stroke is important for health care professionals, health care commissioners, third sector organizations, and stroke survivors to understand the likely progress of poststroke sequelae and to aid in commissioning decisions, planning care, and adjusting to life after stroke. Objective: The primary aim of the Morbidity PRevalence Estimate In StrokE (MORe PREcISE) study is to determine the prevalence of morbidity secondary to a stroke, predictors of morbidity, and trends in quality of life and functional status using patient-reported outcomes, cognitive and functional assessments. Methods: A total of 500 participants will be recruited across Wales and England within 14 days following an admission to a stroke unit for either an ischemic or hemorrhagic stroke as part of a multicenter cohort study. Participants are assessed at baseline ?14 days poststroke and subsequently at 90 (± 14) days and 180 (± 14) days poststroke. At each time point, data will be collected relating to the following domains: participant demographics, routine clinical, patient reported, cognitive status, emotional well-being, and functional ability. Results: Recruitment commenced in October 2018 with 20 sites opened as of September 2019 and was closed on October 31, 2019. Conclusions: The primary outcome is the prevalence of morbidity at 6 months secondary to a stroke. Further analysis will consider temporal changes in the health-related domains to describe trends among baseline, 3-, and 6-month time points. Trial Registration: ClinicalTrials.gov NCT03605381; https://clinicaltrials.gov/ct2/show/NCT03605381 International Registered Report Identifier (IRRID): DERR1-10.2196/15851 UR - https://www.researchprotocols.org/2020/6/e15851 UR - http://dx.doi.org/10.2196/15851 UR - http://www.ncbi.nlm.nih.gov/pubmed/32512539 ID - info:doi/10.2196/15851 ER - TY - JOUR AU - Sakai, Kenichiro AU - Komatsu, Teppei AU - Iguchi, Yasuyuki AU - Takao, Hiroyuki AU - Ishibashi, Toshihiro AU - Murayama, Yuichi PY - 2020/6/9 TI - Reliability of Smartphone for Diffusion-Weighted Imaging?Alberta Stroke Program Early Computed Tomography Scores in Acute Ischemic Stroke Patients: Diagnostic Test Accuracy Study JO - J Med Internet Res SP - e15893 VL - 22 IS - 6 KW - smartphone app KW - DWI KW - ASPECTS N2 - Background: High-quality neuroimages can be viewed using a medical app installed on a smartphone. Although interdevice agreement between smartphone and desktop PC monitor was found to be favorable for evaluating computed tomography images, there are no interdevice agreement data for diffusion-weighted imaging (DWI). Objective: The aim of our study was to compare DWI interpretation using the Join smartphone app with that using a desktop PC monitor, in terms of interdevice and interrater agreement and elapsed interpretation time. Methods: The ischemic change in the DWI of consecutive patients with acute stroke in the middle cerebral artery territory was graded by 2 vascular neurologists using the Join smartphone app and a desktop PC monitor. The vascular neurologists were blinded to all patient information. Each image was categorized as either Diffusion-Weighted Imaging?Alberta Stroke Program Early Computed Tomography Scores (DWI-ASPECTS) ?7 or DWI-ASPECTS <7 according to the Japanese Society for Neuroendovascular Therapy. We analyzed interdevice agreement and interrater agreement with respect to DWI-ASPECTS. Elapsed interpretation time was compared between DWI-ASPECTS evaluated by the Join smartphone app and a desktop PC monitor. Results: We analyzed the images of 111 patients (66% male; median age=69 years; median National Institutes of Health Stroke Scale score on admission=4). Interdevice agreement regarding DWI-ASPECTS between the smartphone and the desktop PC monitor was favorable (vascular neurologist 1: ?=0.777, P<.001, vascular neurologist 2: ?=0.787, P<.001). Interrater agreement was also satisfactory for the smartphone (?=0.710, P<.001) and the desktop PC monitor (?=0.663, P<.001). Median elapsed interpretation time was similar between the smartphone and the desktop PC monitor (vascular neurologist 1: 1.7 min vs 1.6 min; P=.64); vascular neurologist 2: 2.4 min vs 2.0 min; P=.14). Conclusions: The use of a smartphone app enables vascular neurologists to estimate DWI-ASPECTS accurately and rapidly. The Join medical smartphone app shows great promise in the management of acute stroke. UR - https://www.jmir.org/2020/6/e15893 UR - http://dx.doi.org/10.2196/15893 UR - http://www.ncbi.nlm.nih.gov/pubmed/32515744 ID - info:doi/10.2196/15893 ER - TY - JOUR AU - Koka, Avinash AU - Suppan, Laurent AU - Cottet, Philippe AU - Carrera, Emmanuel AU - Stuby, Loric AU - Suppan, Mélanie PY - 2020/6/9 TI - Teaching the National Institutes of Health Stroke Scale to Paramedics (E-Learning vs Video): Randomized Controlled Trial JO - J Med Internet Res SP - e18358 VL - 22 IS - 6 KW - active learning KW - electronic learning KW - video KW - stroke KW - online learning KW - e-learning N2 - Background: Prompt and accurate identification of stroke victims is essential to reduce time from symptom onset to adequate treatment and to improve neurological outcomes. Most neurologists evaluate the extent of neurological deficit according to the National Institutes of Health Stroke Scale (NIHSS), but the use of this scale by paramedics, the first healthcare providers to usually take care of stroke victims, has proven unreliable. This might be, at least in part, due to the teaching method. The video used to teach NIHSS lacks interactivity, while more engaging electronic learning (e-learning) methods might improve knowledge acquisition. Objective: This study was designed to evaluate whether a highly interactive e-learning module could enhance NIHSS knowledge acquisition in paramedics. Methods: A randomized controlled trial comparing a specially designed e-learning module with the original NIHSS video was performed with paramedics working in Geneva, Switzerland. A registration number was not required as our study does not come into the scope of the Swiss federal law on human research. The protocol was nevertheless submitted to the local ethics committee (Project ID 2017-00847), which issued a ?Declaration of no objection.? Paramedics were excluded if they had prior knowledge of or previous training in the NIHSS, or if they had worked in a neurology or neurosurgery ward. The primary outcome was overall performance in the study quiz, which contained 50 questions. Secondary outcomes were performance by NIHSS item, time to course and quiz completion, user satisfaction regarding the learning method, user perception of the course duration, and probability the user would recommend the course to a colleague. Results: The study was completed by 39 paramedics. There was a better overall median score (36/50 vs 33/50, P=.04) and a higher degree of satisfaction regarding the learning method in the e-learning group (90% vs 37%, P=.002). Users who had followed the e-learning module were more likely to recommend the course to a colleague (95% vs 63%, P=.02). Paramedics in the e-learning group took more time to complete the course (93 vs 59 minutes, P<.001), but considered the duration to be more adequate (75% vs 32%, P=.01). Time to quiz completion was similar between groups (25 vs 38 minutes, P=.12). Conclusions: Use of an e-learning module shows promising results in teaching the NIHSS to paramedics. UR - http://www.jmir.org/2020/6/e18358/ UR - http://dx.doi.org/10.2196/18358 UR - http://www.ncbi.nlm.nih.gov/pubmed/32299792 ID - info:doi/10.2196/18358 ER - TY - JOUR AU - Held, Oskar Jeremia Philipp AU - Yu, Kevin AU - Pyles, Connor AU - Veerbeek, Marieke Janne AU - Bork, Felix AU - Heining, Sandro-Michael AU - Navab, Nassir AU - Luft, Rüdiger Andreas PY - 2020/5/26 TI - Augmented Reality?Based Rehabilitation of Gait Impairments: Case Report JO - JMIR Mhealth Uhealth SP - e17804 VL - 8 IS - 5 KW - HoloLens 2 KW - gait KW - rehabilitation KW - stroke KW - augmented reality KW - sensors N2 - Background: Gait and balance impairments are common in neurological diseases, including stroke, and negatively affect patients? quality of life. Improving balance and gait are among the main goals of rehabilitation. Rehabilitation is mainly performed in clinics, which lack context specificity; therefore, training in the patient?s home environment is preferable. In the last decade, developed rehabilitation technologies such as virtual reality and augmented reality (AR) have enabled gait and balance training outside clinics. Here, we propose a new method for gait rehabilitation in persons who have had a stroke in which mobile AR technology and a sensor-based motion capture system are combined to provide fine-grained feedback on gait performance in real time. Objective: The aims of this study were (1) to investigate manipulation of the gait pattern of persons who have had a stroke based on virtual augmentation during overground walking compared to walking without AR performance feedback and (2) to investigate the usability of the AR system. Methods: We developed the ARISE (Augmented Reality for gait Impairments after StrokE) system, in which we combined a development version of HoloLens 2 smart glasses (Microsoft Corporation) with a sensor-based motion capture system. One patient with chronic minor gait impairment poststroke completed clinical gait assessments and an AR parkour course with patient-centered performance gait feedback. The movement kinematics during gait as well as the usability and safety of the system were evaluated. Results: The patient changed his gait pattern during AR parkour compared to the pattern observed during the clinical gait assessments. He recognized the virtual objects and ranked the usability of the ARISE system as excellent. In addition, the patient stated that the system would complement his standard gait therapy. Except for the symptom of exhilaration, no adverse events occurred. Conclusions: This project provided the first evidence of gait adaptation during overground walking based on real-time feedback through visual and auditory augmentation. The system has potential to provide gait and balance rehabilitation outside the clinic. This initial investigation of AR rehabilitation may aid the development and investigation of new gait and balance therapies. UR - http://mhealth.jmir.org/2020/5/e17804/ UR - http://dx.doi.org/10.2196/17804 UR - http://www.ncbi.nlm.nih.gov/pubmed/32452815 ID - info:doi/10.2196/17804 ER - TY - JOUR AU - Li, Li AU - Huang, Jia AU - Wu, Jingsong AU - Jiang, Cai AU - Chen, Shanjia AU - Xie, Guanli AU - Ren, Jinxin AU - Tao, Jing AU - Chan, H. Chetwyn C. AU - Chen, Lidian AU - Wong, K. Alex W. PY - 2020/5/13 TI - A Mobile Health App for the Collection of Functional Outcomes After Inpatient Stroke Rehabilitation: Pilot Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e17219 VL - 8 IS - 5 KW - telemedicine KW - cell phone KW - stroke KW - rehabilitation KW - activities of daily living KW - outcome and process assessment KW - health care N2 - Background: Monitoring the functional status of poststroke patients after they transition home is significant for rehabilitation. Mobile health (mHealth) technologies may provide an opportunity to reach and follow patients post discharge. However, the feasibility and validity of functional assessments administered by mHealth technologies are unknown. Objective: This study aimed to evaluate the feasibility, validity, and reliability of functional assessments administered through the videoconference function of a mobile phone?based app compared with administration through the telephone function in poststroke patients after rehabilitation hospitalization. Methods: A randomized controlled trial was conducted in a rehabilitation hospital in Southeast China. Participants were randomly assigned to either a videoconference follow-up (n=60) or a telephone follow-up (n=60) group. We measured the functional status of participants in each group at 2-week and 3-month follow-up periods. Half the participants in each group were followed by face-to-face home visit assessments as the gold standard. Validity was assessed by comparing any score differences between videoconference follow-up and home visit assessments, as well as telephone follow-up and home visit assessments. Reliability was assessed by computing agreements between videoconference follow-up and home visit assessments, as well as telephone follow-up and home visit assessments. Feasibility was evaluated by the levels of completion, satisfaction, comfort, and confidence in the 2 groups. Results: Scores obtained from the videoconference follow-up were similar to those of the home visit assessment. However, most scores collected from telephone administration were higher than those of the home visit assessment. The agreement between videoconference follow-up and home visit assessments was higher than that between telephone follow-up and home visit assessments at all follow-up periods. In the telephone follow-up group, completion rates were 95% and 82% at 2-week and 3-month follow-up points, respectively. In the videoconference follow-up group, completion rates were 95% and 80% at 2-week and 3-month follow-up points, respectively. There were no differences in the completion rates between the 2 groups at all follow-up periods (X21=1.6, P=.21 for 2-week follow-up; X21=1.9, P=.17 for 3-month follow-up). Patients in the videoconference follow-up group perceived higher confidence than those in the telephone follow-up group at both 2-week and 3-month follow-up periods (X23=6.7, P=.04 for 2-week follow-up; X23=8.0, P=.04 for 3-month follow-up). The videoconference follow-up group demonstrated higher satisfaction than the telephone follow-up group at 3-month follow-up (X23=13.9; P=.03). Conclusions: The videoconference follow-up assessment of functional status demonstrates higher validity and reliability, as well as higher confidence and satisfaction perceived by patients, than the telephone assessment. The videoconference assessment provides an efficient means of assessing functional outcomes of patients after hospital discharge. This method provides a novel solution for clinical trials requiring longitudinal assessments. Trial Registration: chictr.org.cn: ChiCTR1900027626; http://www.chictr.org.cn/edit.aspx?pid=44831&htm=4. UR - https://mhealth.jmir.org/2020/5/e17219 UR - http://dx.doi.org/10.2196/17219 UR - http://www.ncbi.nlm.nih.gov/pubmed/32401221 ID - info:doi/10.2196/17219 ER - TY - JOUR AU - Ifejika, L. Nneka AU - Bhadane, Minal AU - Cai, C. Chunyan AU - Noser, A. Elizabeth AU - Grotta, C. James AU - Savitz, I. Sean PY - 2020/4/22 TI - Use of a Smartphone-Based Mobile App for Weight Management in Obese Minority Stroke Survivors: Pilot Randomized Controlled Trial With Open Blinded End Point JO - JMIR Mhealth Uhealth SP - e17816 VL - 8 IS - 4 KW - smartphone KW - stroke KW - obesity KW - telemedicine KW - minority groups KW - cognitive dysfunction KW - outcome assessment, health care N2 - Background: Minorities have an increased incidence of early-onset, obesity-related cerebrovascular disease. Unfortunately, effective weight management in this vulnerable population has significant barriers. Objective: Our objective was to determine the feasibility and preliminary treatment effects of a smartphone-based weight loss intervention versus food journals to monitor dietary patterns in minority stroke patients. Methods: Swipe out Stroke was a pilot prospective randomized controlled trial with open blinded end point. Minority stroke patients and their caregivers were screened for participation using cluster enrollment. We used adaptive randomization for assignment to a behavior intervention with (1) smartphone-based self-monitoring or (2) food journal self-monitoring. The smartphone group used Lose it! to record meals and communicate with us. Reminder messages (first 30 days), weekly summaries plus reminder messages on missed days (days 31-90), and weekly summaries only (days 91-180) were sent via push notifications. The food journal group used paper diaries. Both groups received 4 in-person visits (baseline and 30, 90, and 180 days), culturally competent counseling, and educational materials. The primary outcome was reduced total body weight. Results: We enrolled 36 stroke patients (n=23, 64% African American; n=13, 36% Hispanic), 17 in the smartphone group, and 19 in the food journal group. Mean age was 54 (SD 9) years; mean body mass index was 35.7 (SD 5.7) kg/m2; education, employment status, and family history of stroke or obesity did not differ between the groups. Baseline rates of depression (Patient Health Questionnaire-9 [PHQ-9] score median 5.5, IQR 3.0-9.5), cognitive impairment (Montreal Cognitive Assessment score median 23.5, IQR 21-26), and inability to ambulate (5/36, 14% with modified Rankin Scale score 3) were similar. In total, 25 (69%) stroke survivors completed Swipe out Stroke (13/17 in the smartphone group, 12/19 in the food journal group); 1 participant in the smartphone group died. Median weight change at 180 days was 5.7 lb (IQR ?2.4 to 8.0) in the smartphone group versus 6.4 lb (IQR ?2.2 to 12.5; P=.77) in the food journal group. Depression was significantly lower at 30 days in the smartphone group than in the food journal group (PHQ-9 score 2 vs 8; P=.03). Clinically relevant depression rates remained in the zero to minimal range for the smartphone group compared with mild to moderate range in the food journal group at day 90 (PHQ-9 score 3.5 vs 4.5; P=.39) and day 180 (PHQ-9 score 3 vs 6; P=.12). Conclusions: In a population of obese minority stroke survivors, the use of a smartphone did not lead to a significant difference in weight change compared with keeping a food journal. The presence of baseline depression (19/36, 53%) was a confounding variable, which improved with app engagement. Future studies that include treatment of poststroke depression may positively influence intervention efficacy. Trial Registration: ClinicalTrials.gov NCT02531074; https://www.clinicaltrials.gov/ct2/show/NCT02531074 UR - http://mhealth.jmir.org/2020/4/e17816/ UR - http://dx.doi.org/10.2196/17816 UR - http://www.ncbi.nlm.nih.gov/pubmed/32319963 ID - info:doi/10.2196/17816 ER - TY - JOUR AU - Zhang, Yuanjin AU - Fan, Dongsheng AU - Ji, Hong AU - Qiao, Shudong AU - Li, Xia PY - 2020/4/15 TI - Treatment Adherence and Secondary Prevention of Ischemic Stroke Among Discharged Patients Using Mobile Phone- and WeChat-Based Improvement Services: Cohort Study JO - JMIR Mhealth Uhealth SP - e16496 VL - 8 IS - 4 KW - stroke KW - secondary prevention KW - WeChat KW - self-monitoring N2 - Background: Real-world studies have indicated that adherence is important for guaranteeing medication effectiveness. Few studies have tested the feasibility and efficacy of WeChat-based improvement services, via mobile phone, in secondary prevention-specific follow-up among discharged stroke patients. Objective: We evaluated a quadruple-domain, WeChat-based service for ischemic stroke secondary prevention designed to improve treatment adherence of discharged patients. This service focuses on sending reminders for drug use, blood pressure recording, and glucose recording; it also records medication use. We compared the endpoint event rate between WeChat self-monitoring and traditional monitoring. Methods: A cohort study was used to determine the feasibility of a physician-assisted, WeChat-based improvement service and follow-up self-monitoring platform for the secondary prevention of ischemic stroke. The platform was developed by the Peking University Third Hospital based on the information-motivation-behavioral skills model. The overall adherence rate was calculated as the proportion of medication doses verified via uploading. The ischemic endpoint event rate and medication noncompliance rate were compared between traditional prevention monitoring and WeChat self-monitoring. Factors influencing adherence were summarized. Results: The 1-year follow-up event rate of the WeChat self-monitoring group was 11.9% (12/101), which was less than that of the traditional group (21/157, 13.4%). Compared with the traditional group, the risk ratio of the WeChat group was 0.983 (95% CI 0.895-1.080); this difference was not noted to be significant. The 1-year medication noncompliance ratio tended to be lower in the WeChat monitoring group (3/101, 3.0%) than in the traditional group (11/157, 7.0%; ?2=1.9, df=1, P=.16). Of the platform registry participants, 89.7% (210/234: 167 hospital-based and 43 community-based participants) adhered to inputting information into WeChat for 8-96 weeks. The average adherence time was 16.54 (SD 0.80, range 2-24) months. The average decrease in adherence was 4 participants (1.1%) per month. Being a member of a community-based population was an influencing factor for good adherence at the 2-year follow-up (OR 2.373, 95% CI 1.019-5.527, P=.045), whereas transient ischemic attack was an influencing factor for poor adherence at the 2-year follow-up (OR 0.122, 95% CI 0.016-0.940, P=.04). Conclusions: Use of WeChat self-monitoring showed a trend of increasing medication compliance and decreasing ischemic endpoint event rate compared with traditional monitoring. However, there were ceiling effects in the outcomes, and a relatively small sample size was used. Male participants displayed better adherence to WeChat self-monitoring. The community-based population displayed good adherence when using WeChat self-monitoring. Trial Registration: ClinicalTrials.gov NCT02618265; https://clinicaltrials.gov/ct2/show/NCT02618265 UR - https://mhealth.jmir.org/2020/4/e16496 UR - http://dx.doi.org/10.2196/16496 UR - http://www.ncbi.nlm.nih.gov/pubmed/32293574 ID - info:doi/10.2196/16496 ER - TY - JOUR AU - Kim, Yeon Do AU - Kwon, Hee AU - Nam, Ki-Woong AU - Lee, Yongseok AU - Kwon, Hyung-Min AU - Chung, Seob Young PY - 2020/2/27 TI - Remote Management of Poststroke Patients With a Smartphone-Based Management System Integrated in Clinical Care: Prospective, Nonrandomized, Interventional Study JO - J Med Internet Res SP - e15377 VL - 22 IS - 2 KW - mHealth KW - mobile apps KW - stroke care KW - health care KW - patient education KW - self-monitoring of blood pressure N2 - Background: Advances in mobile health (mHealth) have enabled systematic and continuous management of patients with chronic diseases. Objective: We developed a smartphone-based mHealth system and aimed to evaluate its effects on health behavior management and risk factor control in stroke patients. Methods: With a multifaceted stroke aftercare management system that included exercise, medication, and educational materials, we performed a 12-week single-arm intervention among eligible poststroke patients in the stroke clinic from September to December 2016. The intervention consisted of (1) regular blood pressure (BP), blood glucose, and physical activity measurements; (2) stroke education; (3) an exercise program; (4) a medication program; and (5) feedback on reviewing of records by clinicians. Clinical assessments consisted of the stroke awareness score, Beck Depression Inventory-II (BDI), EuroQol-5 Dimensions (EQ-5D), and BP at visit 1 (baseline), visit 2 (4 weeks), and visit 3 (12 weeks). Temporal differences in the parameters over 12 weeks were investigated with repeated-measures analysis of variance. Changes in medication adherence at visit 1-2 (from visit 1 to visit 2) and visit 2-3 (from visit 2 to visit 3) were compared. System satisfaction was evaluated with a self-questionnaire using a 5-point Likert scale at visit 3. Results: The study was approved by the Institutional Review Board in September 2016, and participants were enrolled from September to December 2016. Among the 110 patients enrolled for the study, 99 were included in our analyses. The mean stroke awareness score (baseline: 59.6 [SD 18.1]; 4 weeks: 67.6 [SD 16.0], P<.001; 12 weeks: 74.7 [SD 14.0], P<.001) and BDI score (baseline: 12.7 [SD 10.1]; 4 weeks: 11.2 [SD 10.2], P=.01; 12 weeks: 10.7 [SD 10.2], P<.001) showed gradual improvement; however, no significant differences were found in the mean EQ-5D score (baseline: 0.66 [SD 0.33]; 4 weeks: 0.69 [SD 0.34], P=.01; 12 weeks: 0.69 [SD 0.34], P<.001). Twenty-six patients who had uncontrolled BP at baseline had ?13.92 mmHg (P=.001) and ?6.19 mmHg (P<.001) reductions on average in systolic and diastolic BP, respectively, without any antihypertensive medication change. Medication compliance was better at visit 2-3 (60.9% [SD 37.2%]) than at visit 1-2 (47.8% [SD 38.7%], P<.001). Conclusions: Awareness of stroke, depression, and BP was enhanced when using the smartphone-based mHealth system. Emerging mHealth techniques have potential as new nonpharmacological secondary prevention methods because of their ubiquitous access, near real-time responsiveness, and comparatively lower cost. UR - http://www.jmir.org/2020/2/e15377/ UR - http://dx.doi.org/10.2196/15377 UR - http://www.ncbi.nlm.nih.gov/pubmed/32130140 ID - info:doi/10.2196/15377 ER - TY - JOUR AU - Kamal, Ayeesha AU - Khoja, Adeel AU - Usmani, Bushra AU - Magsi, Shahvaiz AU - Malani, Aresha AU - Peera, Zahra AU - Sattar, Saadia AU - Ahmed Akram, Masood AU - Shahnawaz, Sumaira AU - Zulfiqar, Maryam AU - Muqeet, Abdul AU - Zaidi, Fabiha AU - Sayani, Saleem AU - Artani, Azmina AU - Azam, Iqbal AU - Saleem, Sarah PY - 2020/1/28 TI - Effect of 5-Minute Movies Shown via a Mobile Phone App on Risk Factors and Mortality After Stroke in a Low- to Middle-Income Country: Randomized Controlled Trial for the Stroke Caregiver Dyad Education Intervention (Movies4Stroke) JO - JMIR Mhealth Uhealth SP - e12113 VL - 8 IS - 1 KW - stroke KW - mobile health KW - noncommunicable diseases KW - adherence N2 - Background: Pakistan is the sixth most populous nation in the world and has an estimated 4 million stroke survivors. Most survivors are taken care of by community-based caregivers, and there are no inpatient rehabilitation facilities. Objective: The objective of this study was to evaluate the effectiveness and safety of locally designed 5-min movies rolled out in order of relevance that are thematically delivered in a 3-month program to deliver poststroke education to stroke survivor and caregiver dyads returning to the community. Methods: This study was a randomized controlled, outcome assessor?blinded, parallel group, single-center superiority trial in which participants (stroke survivor-caregiver dyads) with first-ever stroke (both ischemic and hemorrhagic) incidence were randomized within 48 hours of their stroke into either the video-based education intervention group or the control group. The video-based education intervention group had health education delivered through short videos that were shown to the participants and their caregivers at the time of admission, before discharge, and the first and third months of follow-up after discharge. The control group had standardized care including predischarge education and counseling according to defined protocols. All participants enrolled in the video education intervention and control groups were followed for 12 months after discharge for outcome assessment in the outpatient stroke clinics. The primary outcome measures were the proportion of participants achieving control of blood pressure, blood sugar, and blood cholesterol in the video intervention versus the control group. Several predefined secondary outcomes were included in this study, of which we report the mortality and functional disability in this paper. Analysis was by performed using the intention-to-treat principle. Results: A total of 310 stroke survivors and their caregiver dyads (participant dyads) were recruited over a duration of 6 months. In total, 155 participant dyads were randomized into the intervention and control groups, each. The primary outcome of control of three major risk factors revealed that at 12 months, there was a greater percentage of participants with a systolic BP<125 mm Hg (18/54, 33% vs 11/52, 21%; P=.16), diastolic BP<85 mm Hg (44/54, 81% vs 37/52, 71%; P=.21), HbA1c level<7% (36/55, 65% vs 30/40, 75%; P=.32), and low-density lipoprotein level<100 mg/dL (36/51, 70% vs 30/45, 67%; P=.68) in the intervention group than in the control group. The secondary outcome reported is the mortality among the stroke survivors because the number of stroke-related complications was higher in the control group than in the intervention group (13/155, 8.4% vs 2/155, 1.3%), and this difference was statistically significant (P<.001). Conclusions: The Movies4Stroke trial failed to achieve its primary specified outcome. However, secondary outcomes that directly related to survival skills of stroke survivors demonstrated the effectiveness of the video-based intervention on improving stroke-related mortality and survival without disability. Trial Registration: ClinicalTrials.gov NCT02202330; https://www.clinicaltrials.gov/ct2/show/NCT02202330 UR - http://mhealth.jmir.org/2020/1/e12113/ UR - http://dx.doi.org/10.2196/12113 UR - http://www.ncbi.nlm.nih.gov/pubmed/32012080 ID - info:doi/10.2196/12113 ER - TY - JOUR AU - Parker, Jack AU - Powell, Lauren AU - Mawson, Susan PY - 2020/1/8 TI - Effectiveness of Upper Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: Systematic Review JO - J Med Internet Res SP - e15981 VL - 22 IS - 1 KW - wearable electronic devices KW - stroke KW - rehabilitation KW - upper extremity N2 - Background: With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Upper limb (UL) impairment affects up to 77% of stroke survivors impacting on their ability to carry out everyday activities. However, despite an increase in research exploring these devices for UL rehabilitation, little is known of their effectiveness. Objective: This review aimed to assess the effectiveness of UL wearable technology for improving activity and participation in adult stroke survivors. Methods: Randomized controlled trials (RCTs) and randomized comparable trials of UL wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability, and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs and the Downs and Black Instrument for the quality of non RCTs. Results: In the review, we included 11 studies with collectively 354 participants at baseline and 323 participants at final follow-up including control groups and participants poststroke. Participants? stroke type and severity varied. Only 1 study found significant between-group differences for systems functioning and activity (P?.02). The 11 included studies in this review had small sample sizes ranging from 5 to 99 participants at an average (mean) age of 57 years. Conclusions: This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes and the appropriateness of the methodology for complex interventions. However, technology has the potential to measure outcomes, provide feedback, and engage users outside of clinical sessions. This could provide a platform for motivating stroke survivors to carry out more rehabilitation in the absence of a therapist, which could maximize recovery. Trial Registration: PROSPERO CRD42017057715; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=57715 UR - https://www.jmir.org/2020/1/e15981 UR - http://dx.doi.org/10.2196/15981 UR - http://www.ncbi.nlm.nih.gov/pubmed/31913131 ID - info:doi/10.2196/15981 ER - TY - JOUR AU - Gong, Enying AU - Gu, Wanbing AU - Luo, Erdan AU - Tan, Liwei AU - Donovan, Julian AU - Sun, Cheng AU - Yang, Ying AU - Zang, Longkai AU - Bao, Peng AU - Yan, L. Lijing PY - 2019/12/17 TI - Development and Local Contextualization of Mobile Health Messages for Enhancing Disease Management Among Community-Dwelling Stroke Patients in Rural China: Multimethod Study JO - JMIR Mhealth Uhealth SP - e15758 VL - 7 IS - 12 KW - phone messages KW - stroke KW - secondary prevention KW - rural population KW - China N2 - Background: Rural China has experienced an increasing health burden because of stroke. Stroke patients in rural communities have relatively poor awareness of and adherence to evidence-based secondary prevention and self-management of stroke. Mobile technology represents an innovative way to influence patient behaviors and improve their self-management. Objective: This study is part of the System-Integrated Technology-Enabled Model of Care (the SINEMA trial) to improve the health of stroke patients in resource-poor settings in China. This study aimed to develop and pilot-test a mobile phone message?based package, as a component of the SINEMA intervention. Methods: The SINEMA trial was conducted in Nanhe County, Hebei Province, China. A total of 4 villages were selected for pretrial contextual research and pilot study. The 5 stages for developing the mobile phone messages were as follows: (1) conducting literature review on existing message banks and analyzing the characteristics of these banks; (2) interviewing stroke patients and caregivers to identify their needs; (3) drafting message contents and designing dispatching algorithms for a 3-month pilot testing; (4) collecting feedback from pilot participants through questionnaire survey and in-depth interviews on facilitators and barriers related to their acceptance and understanding of messages; and (5) finalizing the message-based intervention based on participants? feedback for the SINEMA trial. Results: On the basis of 5 existing message banks screened out of 120 papers and patients? needs identified from 32 in-depth interviews among stroke patients and caregivers, we developed a message bank containing 224 messages for a pilot study among 54 community-dwelling stroke patients from 4 villages. Of 54 participants, 51 (response rate: 94.4%) completed the feedback survey after receiving daily messages for 3 months. Participants? mean age was 68 years (SD 9.2), and about half had never been to school. We observed a higher proportion of participants who were in favor of voice messages (23/42, 54%) than text messages (14/40, 35%). Among participants who received voice messages (n=43) and text messages (n=40), 41 and 30, respectively, self-reported a full or partial understanding of the contents, and 39 (39/43, 91%) and 32 (32/40, 80%), respectively, rated the messages as helpful. Analyses of the 32 interviews further revealed that voice messages containing simple and single-theme content, in plain language, with a repeated structure, a slow playback speed, and recorded in local dialect, were preferred by rural stroke patients. In addition, the dispatching algorithm and tools may also influence the acceptance of message-based interventions. Conclusions: By applying multiple methodologies and conducting a pilot study, we designed and fine-tuned a voice message?based intervention package for promoting secondary prevention among community-dwelling stroke patients in rural China. Design of the content and dispatching algorithm should engage both experts and end users and adequately consider the needs and preferences of recipients. UR - https://mhealth.jmir.org/2019/12/e15758 UR - http://dx.doi.org/10.2196/15758 UR - http://www.ncbi.nlm.nih.gov/pubmed/31845901 ID - info:doi/10.2196/15758 ER - TY - JOUR AU - Johnson, Louise AU - Burridge, Jane AU - Demain, Sara AU - Ewings, Sean PY - 2019/11/5 TI - Comparing the Impact of an Implicit Learning Approach With Standard Care on Recovery of Mobility Following Stroke: Protocol for a Pilot Cluster Randomized Controlled Trial JO - JMIR Res Protoc SP - e14222 VL - 8 IS - 11 KW - stroke KW - rehabilitation KW - learning KW - attention N2 - Background: Although implicit and explicit learning approaches have been well investigated in healthy populations, there is less evidence regarding the relative benefits of each approach in clinical practice. Studies in stroke typically investigate single elements of an implicit learning approach (ILA; eg, reduced quantity feedback or an external focus of attention) within controlled environments. These studies predominantly evaluate performance, with few measuring this over time (ie, learning). The relevance and transferability of current research evidence into stroke rehabilitation is therefore limited. Objective: The objective of this study was to compare the ILA with standard care in the acute phase following stroke, to generate data and insights to inform the design of a definitive trial, and to understand patient and therapist perceptions of the ILA. Methods: This is a multicenter, assessor-blind, cluster randomized controlled pilot trial with nested qualitative evaluation. Stroke units (clusters) will be randomized to either ILA (intervention) or standard care (control) arms. Therapy teams at the intervention sites will be trained in the ILA and provided with an intervention manual. Those at the control sites will have minimal input from the research team, other than for data collection. Consent will be provided at the individual participant level. Once enrolled, participants will receive rehabilitation that focuses on lower limb recovery, using the designated approach. Measures will be taken at baseline, every 2 weeks until the point of discharge from hospital, and at 3 months post stroke onset. Measures include the Fugl Meyer Assessment (motor leg subsection), modified Rivermead Mobility Index, Swedish Postural Adjustment in Stroke Scale, and achievement of mobility milestones. Fidelity of the treatment approach will be monitored using observational video analysis. Focus groups and interviews will be used to gain insight into the perceptions of trial participants and clinical teams. Results: The first site opened to recruitment in February 2019. The opening of a further 5 sites will be staggered throughout 2019. Results are expected in early 2021. Conclusions: The findings from this mixed methods pilot study will be used to inform the design of a definitive study, comparing the ILA with standard care in acute stroke rehabilitation. Trial Registration: ClinicalTrials.gov NCT03792126; https://clinicaltrials.gov/ct2/show/NCT03792126 International Registered Report Identifier (IRRID): DERR1-10.2196/14222 UR - https://www.researchprotocols.org/2019/11/e14222 UR - http://dx.doi.org/10.2196/14222 UR - http://www.ncbi.nlm.nih.gov/pubmed/31687935 ID - info:doi/10.2196/14222 ER - TY - JOUR AU - Wang, Guangyu AU - Zhou, Silu AU - Rezaei, Shahbaz AU - Liu, Xin AU - Huang, Anpeng PY - 2019/10/30 TI - An Ambulatory Blood Pressure Monitor Mobile Health System for Early Warning for Stroke Risk: Longitudinal Observational Study JO - JMIR Mhealth Uhealth SP - e14926 VL - 7 IS - 10 KW - ambulatory blood pressure monitor KW - mHealth KW - stroke-risk early warning KW - abnormal blood pressure data analyzing KW - longitudinal observational study N2 - Background: Stroke, as a leading cause of death around the globe, has become a heavy burden on our society. Studies show that stroke can be predicted and prevented if a person?s blood pressure (BP) status is appropriately monitored via an ambulatory blood pressure monitor (ABPM) system. However, currently there exists no efficient and user-friendly ABPM system to provide early warning for stroke risk in real-time. Moreover, most existing ABPM devices measure BP during the deflation of the cuff, which fails to reflect blood pressure accurately. Objective: In this study, we sought to develop a new ABPM mobile health (mHealth) system that was capable of monitoring blood pressure during inflation and could detect early stroke-risk signals in real-time. Methods: We designed an ABPM mHealth system that is based on mobile network infrastructure and mobile apps. The proposed system contains two major parts: a new ABPM device in which an inflation-type BP measurement algorithm is embedded, and an abnormal blood pressure data analysis algorithm for stroke-risk prediction services at our health data service center. For evaluation, the ABPM device was first tested using simulated signals and compared with the gold standard of a mercury sphygmomanometer. Then, the performance of our proposed mHealth system was evaluated in an observational study. Results: The results are presented in two main parts: the device test and the longitudinal observational studies of the presented system. The average measurement error of the new ABPM device with the inflation-type algorithm was less than 0.55 mmHg compared to a reference device using simulated signals. Moreover, the results of correlation coefficients and agreement analyses show that there is a strong linear correlation between our device and the standard mercury sphygmomanometer. In the case of the system observational study, we collected a data set with 88 features, including real-time data, user information, and user records. Our abnormal blood pressure data analysis algorithm achieved the best performance, with an area under the curve of 0.904 for the low risk level, 0.756 for the caution risk level, and 0.912 for the high-risk level. Our system enables a patient to be aware of their risk in real-time, which improves medication adherence with risk self-management. Conclusions: To our knowledge, this device is the first ABPM device that measures blood pressure during the inflation process and has obtained a government medical license. Device tests and longitudinal observational studies were conducted in Peking University hospitals, and they showed the device?s high accuracy for BP measurements, its efficiency in detecting early signs of stroke, and its efficiency at providing an early warning for stroke risk. UR - http://mhealth.jmir.org/2019/10/e14926/ UR - http://dx.doi.org/10.2196/14926 UR - http://www.ncbi.nlm.nih.gov/pubmed/31670694 ID - info:doi/10.2196/14926 ER - TY - JOUR AU - Driver, Simon AU - Swank, Chad AU - Froehlich-Grobe, Katherine AU - McShan, Evan AU - Calhoun, Stephanie AU - Bennett, Monica PY - 2019/10/18 TI - Weight Loss After Stroke Through an Intensive Lifestyle Intervention (Group Lifestyle Balance-Cerebrovascular Accident): Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e14338 VL - 8 IS - 10 KW - cerebrovascular accident KW - physical activity KW - eating KW - weight loss KW - rehabilitation N2 - Background: Weight gain can be a consequence of stroke, or cerebrovascular accident (CVA), because of impaired mobility, behavioral and emotional disorders, and sensory losses. Weight gain increases the patient?s risk of recurrent stroke and chronic diseases, such as diabetes, metabolic syndrome, and pulmonary and heart disease. Approaches to weight loss in this population are lacking, although necessary because of the unique physiological and cognitive needs of persons after a stroke. Evidence shows that intensive behavioral therapy interventions that address both physical activity and diet offer the greatest potential for weight loss. The Group Lifestyle Balance (GLB) intervention is a 12-month, evidence-based weight loss program that has been used extensively with the general population; this program was modified to meet the needs of people who have had a stroke (GLB-CVA). Objective: This randomized controlled trial (RCT) aims to examine the efficacy of the GLB-CVA on weight and secondary outcomes, compared with that of a waitlist control group. Methods: This RCT will enroll and randomize 64 patients over an 18-month period. Results: Currently, 51 people are waitlisted, with 23 out of 51 screened and 16 out of 23 eligible. Conclusions: It is anticipated that the findings from this RCT will contribute to the evidence base regarding weight loss strategies for people living with stroke. Clinical Trial: ClinicalTrials.gov NCT03873467; https://clinicaltrials.gov/ct2/show/NCT03873467 UR - https://www.researchprotocols.org/2019/10/e14338 UR - http://dx.doi.org/10.2196/14338 UR - http://www.ncbi.nlm.nih.gov/pubmed/31628790 ID - info:doi/10.2196/14338 ER - TY - JOUR AU - Tsurushima, Hideo AU - Mizukami, Masafumi AU - Yoshikawa, Kenichi AU - Ueno, Tomoyuki AU - Hada, Yasushi AU - Gosho, Masahiko AU - Kohno, Yutaka AU - Hashimoto, Koichi AU - Iizumi, Yuichi AU - Kikuchi, Toshihiro AU - Matsumura, Akira AU - PY - 2019/10/11 TI - Effectiveness of a Walking Program Involving the Hybrid Assistive Limb Robotic Exoskeleton Suit for Improving Walking Ability in Stroke Patients: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e14001 VL - 8 IS - 10 KW - Hybrid Assistive Limb (HAL) KW - gait training KW - stroke KW - hemiparesis N2 - Background: Gait disturbance often occurs in stroke survivors. Recovery of walking function is challenging, as some gait disturbance due to hemiparesis often remains even after rehabilitation therapy, presenting a major obstacle towards regaining activities-of-daily-living performance and achieving social reintegration. Objective: This study aims to clarify the effectiveness of a walking program involving the wearable Hybrid Assistive Limb (HAL-TS01) robotic exoskeleton for improving walking ability in stroke patients with hemiparesis and stagnant recovery despite ongoing rehabilitation. Methods: This is a multicenter, randomized, parallel-group, controlled study (HAL group, n=27; control group, n=27). The study period includes preintervention observation (until stagnant recovery), intervention (HAL-based walking therapy or conventional rehabilitation; 5 weeks), and postintervention observation (2 weeks). Following provision of informed consent and primary registration, the patients undergo conventional rehabilitation for preintervention observation, during which the recovery of walking ability is monitored to identify patients with stagnant recovery (based on weekly assessments using the 10-meter maximum walking speed [MWS] test). Patients with an MWS of 30-60 m/minute and insufficient weekly improvement in MWS undergo secondary registration and are randomly assigned to undergo HAL-based walking therapy (HAL group) or conventional rehabilitation (control group). The primary outcome is the change in MWS from baseline to the end of the 5-week intervention. Results: This study began in November 2016 and is being conducted at 15 participating facilities in Japan. Conclusions: Assessments of walking ability vary greatly and it is difficult to define the threshold for significant differences. To reduce such variability, our study involves conducting conventional rehabilitation to the point of saturation before starting the intervention. Stagnation in the recovery of walking ability despite conventional rehabilitation highlights the limits of current medical care. The present study may bring evidence that HAL-based therapy can overcome such limitations and induce added recovery of walking ability, which would promote the use of HAL technology in the clinical setting. Trial Registration: UMIN Clinical Trials Registry UMIN000024805; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000028545 UR - https://www.researchprotocols.org/2019/10/e14001 UR - http://dx.doi.org/10.2196/14001 UR - http://www.ncbi.nlm.nih.gov/pubmed/31605515 ID - info:doi/10.2196/14001 ER - TY - JOUR AU - Appireddy, Ramana AU - Khan, Sana AU - Leaver, Chad AU - Martin, Cally AU - Jin, Albert AU - Durafourt, A. Bryce AU - Archer, L. Stephen PY - 2019/10/7 TI - Home Virtual Visits for Outpatient Follow-Up Stroke Care: Cross-Sectional Study JO - J Med Internet Res SP - e13734 VL - 21 IS - 10 KW - telemedicine KW - eHealth KW - eVisit KW - mobile health KW - health services accessibility N2 - Background: Timely, in-person access to health care is a challenge for people living with conditions such as stroke that result in frailty, loss of independence, restrictions in driving and mobility, and physical and cognitive decline. In Southeastern Ontario, access is further complicated by rurality and the long travel distances to visit physician clinics. There is a need to make health care more accessible and convenient. Home virtual visits (electronic visits, eVisits) can conveniently connect physicians to patients. Physicians use a secure personal videoconferencing tool to connect to patients in their homes. Patients use their device of choice (smartphone, tablet, laptop, or desktop) for the visit. Objective: This study aimed to assess the feasibility and logistics of implementing eVisits in a stroke prevention clinic for seniors. Methods: A 6-month eVisit pilot study was initiated in the Kingston Health Sciences Centre stroke prevention clinic in August 2018. eVisits were used only for follow-up patient encounters. An integrated evaluation was used to test the impact of the program on clinic workflow and patient satisfaction. Patient satisfaction was evaluated by telephone interviews, using a brief questionnaire. Access and patient satisfaction metrics were compared with concurrent standard of care (patients? prior personal experience with in-person visits). Values are presented as median (interquartile range). Results: There were 75 subjects in the pilot. The patients were aged 65 (56-73.5) years, and 39% (29/75) resided in rural areas. There was a shorter wait for an appointment by eVisit versus in-person (mean 59.98 [SD 48.36] days vs mean 78.36 [SD 50.54] days; P<.001). The eVisit was also shorter, taking on an average of only 10 min to deliver follow-up care with a high degree of patient satisfaction versus 90 (60-112) min for in-person care. The total time saved by patients per eVisit was 80 (50-102) min, 44 (21-69) min of which was travel time. Travel distance avoided by the patients was 30.1 km (11.2-82.2). The estimated total out-of-pocket cost savings for patients per eVisit was Can $52.83 (31.26-94.53). The estimated savings (opportunity cost for in-person outpatient care) for our eVisit pilot project was Can $23,832-$28,584. The patient satisfaction with eVisits was very good compared with their prior personal experience with in-person outpatient care. Conclusions: The eVisit program was well received by patients, deemed to be safe by physicians, and avoided unnecessary patient travel and expense. It also has the potential to reduce health care costs. We plan to scale the project within the department and the institution. UR - https://www.jmir.org/2019/10/e13734 UR - http://dx.doi.org/10.2196/13734 UR - http://www.ncbi.nlm.nih.gov/pubmed/31593536 ID - info:doi/10.2196/13734 ER - TY - JOUR AU - Mubin, Omar AU - Alnajjar, Fady AU - Jishtu, Nalini AU - Alsinglawi, Belal AU - Al Mahmud, Abdullah PY - 2019/9/8 TI - Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients? Rehabilitation: Systematic Review JO - JMIR Rehabil Assist Technol SP - e12010 VL - 6 IS - 2 KW - stroke KW - robot KW - exoskeleton KW - virtual reality KW - augmented reality KW - gamification KW - rehabilitation N2 - Background: Robot-assisted therapy has become a promising technology in the field of rehabilitation for poststroke patients with motor disorders. Motivation during the rehabilitation process is a top priority for most stroke survivors. With current advancements in technology there has been the introduction of virtual reality (VR), augmented reality (AR), customizable games, or a combination thereof, that aid robotic therapy in retaining, or increasing the interests of, patients so they keep performing their exercises. However, there are gaps in the evidence regarding the transition from clinical rehabilitation to home-based therapy which calls for an updated synthesis of the literature that showcases this trend. The present review proposes a categorization of these studies according to technologies used, and details research in both upper limb and lower limb applications. Objective: The goal of this work was to review the practices and technologies implemented in the rehabilitation of poststroke patients. It aims to assess the effectiveness of exoskeleton robotics in conjunction with any of the three technologies (VR, AR, or gamification) in improving activity and participation in poststroke survivors. Methods: A systematic search of the literature on exoskeleton robotics applied with any of the three technologies of interest (VR, AR, or gamification) was performed in the following databases: MEDLINE, EMBASE, Science Direct & The Cochrane Library. Exoskeleton-based studies that did not include any VR, AR or gamification elements were excluded, but publications from the years 2010 to 2017 were included. Results in the form of improvements in the patients? condition were also recorded and taken into consideration in determining the effectiveness of any of the therapies on the patients. Results: Thirty studies were identified based on the inclusion criteria, and this included randomized controlled trials as well as exploratory research pieces. There were a total of about 385 participants across the various studies. The use of technologies such as VR-, AR-, or gamification-based exoskeletons could fill the transition from the clinic to a home-based setting. Our analysis showed that there were general improvements in the motor function of patients using the novel interfacing techniques with exoskeletons. This categorization of studies helps with understanding the scope of rehabilitation therapies that can be successfully arranged for home-based rehabilitation. Conclusions: Future studies are necessary to explore various types of customizable games required to retain or increase the motivation of patients going through the individual therapies. UR - https://rehab.jmir.org/2019/2/e12010 UR - http://dx.doi.org/10.2196/12010 UR - http://www.ncbi.nlm.nih.gov/pubmed/31586360 ID - info:doi/10.2196/12010 ER - TY - JOUR AU - Garcia-Rudolph, Alejandro AU - Laxe, Sara AU - Saurí, Joan AU - Bernabeu Guitart, Montserrat PY - 2019/08/26 TI - Stroke Survivors on Twitter: Sentiment and Topic Analysis From a Gender Perspective JO - J Med Internet Res SP - e14077 VL - 21 IS - 8 KW - stroke KW - emotions KW - Twitter KW - infodemiology KW - infoveillance KW - sentiment analysis KW - topic models KW - gender N2 - Background: Stroke is the worldwide leading cause of long-term disabilities. Women experience more activity limitations, worse health-related quality of life, and more poststroke depression than men. Twitter is increasingly used by individuals to broadcast their day-to-day happenings, providing unobtrusive access to samples of spontaneously expressed opinions on all types of topics and emotions. Objective: This study aimed to consider the raw frequencies of words in the collection of tweets posted by a sample of stroke survivors and to compare the posts by gender of the survivor for 8 basic emotions (anger, fear, anticipation, surprise, joy, sadness, trust and disgust); determine the proportion of each emotion in the collection of tweets and statistically compare each of them by gender of the survivor; extract the main topics (represented as sets of words) that occur in the collection of tweets, relative to each gender; and assign happiness scores to tweets and topics (using a well-established tool) and compare them by gender of the survivor. Methods: We performed sentiment analysis based on a state-of-the-art lexicon (National Research Council) with syuzhet R package. The emotion scores for men and women were first subjected to an F-test and then to a Wilcoxon rank sum test. We extended the emotional analysis, assigning happiness scores with the hedonometer (a tool specifically designed considering Twitter inputs). We calculated daily happiness average scores for all tweets. We created a term map for an exploratory clustering analysis using VosViewer software. We performed structural topic modelling with stm R package, allowing us to identify main topics by gender. We assigned happiness scores to all the words defining the main identified topics and compared them by gender. Results: We analyzed 800,424 tweets posted from August 1, 2007 to December 1, 2018, by 479 stroke survivors: Women (n=244) posted 396,898 tweets, and men (n=235) posted 403,526 tweets. The stroke survivor condition and gender as well as membership in at least 3 stroke-specific Twitter lists of active users were manually verified for all 479 participants. Their total number of tweets since 2007 was 5,257,433; therefore, we analyzed the most recent 15.2% of all their tweets. Positive emotions (anticipation, trust, and joy) were significantly higher (P<.001) in women, while negative emotions (disgust, fear, and sadness) were significantly higher (P<.001) in men in the analysis of raw frequencies and proportion of emotions. Happiness mean scores throughout the considered period show higher levels of happiness in women. We calculated the top 20 topics (with percentages and CIs) more likely addressed by gender and found that women?s topics show higher levels of happiness scores. Conclusions: We applied two different approaches?the Plutchik model and hedonometer tool?to a sample of stroke survivors? tweets. We conclude that women express positive emotions and happiness much more than men. UR - http://www.jmir.org/2019/8/e14077/ UR - http://dx.doi.org/10.2196/14077 UR - http://www.ncbi.nlm.nih.gov/pubmed/31452514 ID - info:doi/10.2196/14077 ER - TY - JOUR AU - Appalasamy, Rani Jamuna AU - Subramanian, Pathmavathi AU - Tan, Mun Kit AU - Seeta Ramaiah, Siva AU - Joseph, Pauline Joyce AU - Chua, Siang Siew PY - 2019/07/22 TI - The Needs and Barriers of Medication-Taking Self-Efficacy Among Poststroke Patients: Qualitative Study JO - JMIR Nursing SP - e14399 VL - 2 IS - 1 KW - poststroke KW - medication taking self-efficacy KW - medication adherence N2 - Background: Stroke is one of the top 10 leading diseases worldwide, with high mortality and morbidity rates. There is an incomplete understanding of the various types of self-efficacy involved in the prevention of recurrent stroke, and one of them is medication-taking self-efficacy. Objective: This study aimed to explore the fundamental needs and barriers of medication-taking self-efficacy in poststroke patients in Malaysia. Methods: We performed in-depth individual interviews with poststroke patients (N=10) from the Outpatient Neurology Clinic, Hospital Kuala Lumpur. All interviews were transcribed verbatim, and an inductive thematic analysis was performed on the data collected from the interviews. Results: Two key themes were identified: (1) self-efficacy in taking the effort to understand stroke and its preventative treatment for recurrent stroke and (2) self-efficacy in taking prescribed medication to prevent stroke. Patients needed to be proactive in seeking reliable information about stroke and the perceived benefits of preventative treatment for stroke. The discussion was focused on eliciting the needs and barriers related to medication-taking self-efficacy. Patients needed to develop independence and self-reliance to overcome barriers such as dependency and low motivation. External factors such as limited information resources, low perceived severity, poor social environment, and poor communication add to the challenges of poststroke patients to improve their self-efficacy of managing their medications. Conclusions: The study identified potential key findings related to the needs of patients in a localized setting, which are also related to several health behavioral concepts and constructs, indicating the importance of overcoming barriers to improve the quality of life in poststroke patients. We anticipate that the results will be taken into consideration for future personalized patient education interventions. UR - https://nursing.jmir.org/2019/1/e14399/ UR - http://dx.doi.org/10.2196/14399 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/14399 ER - TY - JOUR AU - Wu, Na AU - Gong, Enying AU - Wang, Bo AU - Gu, Wanbing AU - Ding, Nan AU - Zhang, Zhuoran AU - Chen, Mengyao AU - Yan, L. Lijing AU - Oldenburg, Brian AU - Xu, Li-Qun PY - 2019/07/19 TI - A Smart and Multifaceted Mobile Health System for Delivering Evidence-Based Secondary Prevention of Stroke in Rural China: Design, Development, and Feasibility Study JO - JMIR Mhealth Uhealth SP - e13503 VL - 7 IS - 7 KW - stroke KW - secondary prevention KW - rural health services KW - mobile application KW - software design KW - China N2 - Background: Mobile health (mHealth) technologies hold great promise in improving the delivery of high-quality health care services. Yet, there has been little research so far applying mHealth technologies in the context of delivering stroke care in resource-limited rural regions. Objective: This study aimed to introduce the design and development of an mHealth system targeting primary health care providers and to ascertain its feasibility in supporting the delivery of a System-Integrated techNology-Enabled Model of cAre (SINEMA) service for strengthening secondary prevention of stroke in rural China. Methods: The SINEMA mHealth system was designed by a multidisciplinary team comprising public health researchers, neurologists, and information and communication technology experts. The iterative co-design and development of the mHealth system involved the following 5 steps: (1) assessing the needs of relevant end users through in-depth interviews of stakeholders, (2) designing the functional modules and evidence-based care content, (3) designing and building the system and user interface, (4) improving and enhancing the system through a 3-month pilot test in 4 villages, and (5) finalizing the system and deploying it in field trial, and finally, evaluating its feasibility through a survey of the dominant user group. Results: From the in-depth interviews of 49 relevant stakeholders, we found that village doctors had limited capacity in caring for village-dwelling stroke patients in rural areas. Primary health care workers demonstrated real needs in receiving appropriate training and support from the mHealth system as well as great interests in using the mHealth technologies and tools. Using these findings, we designed a multifaceted mHealth system with 7 functional modules by following the iterative user-centered design and software development approach. The mHealth system, aimed at 3 different types of users (village doctors, town physicians, and county managers), was developed and utilized in a cluster-randomized controlled trial by 25 village doctors in a resource-limited county in rural China to manage 637 stroke patients between July 2017 and July 2018. In the end, a survey on the usability and functions of the mHealth system among village doctors (the dominant group of users, response rate=96%, 24/25) revealed that most of them were satisfied with the essential functions provided (71%) and were keen to continue using it (92%) after the study. Conclusions: The mHealth system was feasible for assisting primary health care providers in rural China in delivering the SINEMA service on the secondary prevention of stroke. Further research and initiatives in scaling up the SINEMA approach and this mHealth system to other resource-limited regions in China and beyond will likely enhance the quality and accessibility of essential secondary prevention among stroke patients. ClinicalTrial: ClinicalTrials.gov NCT03185858; https://clinicaltrials.gov/ct2/show/NCT03185858 International Registered Report Identifier (IRRID): RR2-10.1016/j.ahj.2018.08.015 UR - http://mhealth.jmir.org/2019/7/e13503/ UR - http://dx.doi.org/10.2196/13503 UR - http://www.ncbi.nlm.nih.gov/pubmed/31325288 ID - info:doi/10.2196/13503 ER - TY - JOUR AU - Jiang, Xinchan AU - Ming, Wai-Kit AU - You, HS Joyce PY - 2019/06/17 TI - The Cost-Effectiveness of Digital Health Interventions on the Management of Cardiovascular Diseases: Systematic Review JO - J Med Internet Res SP - e13166 VL - 21 IS - 6 KW - telemedicine KW - cardiovascular diseases KW - stroke KW - heart failure KW - myocardial infarction KW - heart attack KW - cost-effectiveness KW - medical economics KW - decision modeling KW - systematic review N2 - Background: With the advancement in information technology and mobile internet, digital health interventions (DHIs) are improving the care of cardiovascular diseases (CVDs). The impact of DHIs on cost-effective management of CVDs has been examined using the decision analytic model?based health technology assessment approach. Objective: The aim of this study was to perform a systematic review of the decision analytic model?based studies evaluating the cost-effectiveness of DHIs on the management of CVDs. Methods: A literature review was conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature Complete, PsycINFO, Scopus, Web of Science, Center for Review and Dissemination, and Institute for IEEE Xplore between 2001 and 2018. Studies were included if the following criteria were met: (1) English articles, (2) DHIs that promoted or delivered clinical interventions and had an impact on patients? cardiovascular conditions, (3) studies that were modeling works with health economic outcomes of DHIs for CVDs, (4) studies that had a comparative group for assessment, and (5) full economic evaluations including a cost-effectiveness analysis, cost-utility analysis, cost-benefit analysis, and cost-consequence analysis. The primary outcome collected was the cost-effectiveness of the DHIs, presented by incremental cost per additional quality-adjusted life year (QALY). The quality of each included study was evaluated using the Consolidated Health Economic Evaluation Reporting Standards. Results: A total of 14 studies met the defined criteria and were included in the review. Among the included studies, heart failure (7/14, 50%) and stroke (4/14, 29%) were two of the most frequent CVDs that were managed by DHIs. A total of 9 (64%) studies were published between 2015 and 2018 and 5 (36%) published between 2011 and 2014. The time horizon was ?1 year in 3 studies (21%), >1 year in 10 studies (71%), and 1 study (7%) did not declare the time frame. The types of devices or technologies used to deliver the health interventions were short message service (1/14, 7%), telephone support (1/14, 7%), mobile app (1/14, 7%), video conferencing system (5/14, 36%), digital transmission of physiologic data (telemonitoring; 5/14, 36%), and wearable medical device (1/14, 7%). The DHIs gained higher QALYs with cost saving in 43% (6/14) of studies and gained QALYs at a higher cost at acceptable incremental cost-effectiveness ratio (ICER) in 57% (8/14) of studies. The studies were classified as excellent (0/14, 0%), good (9/14, 64%), moderate (4/14, 29%), and low (1/14, 7%) quality. Conclusions: This study is the first systematic review of decision analytic model?based cost-effectiveness analyses of DHIs in the management of CVDs. Most of the identified studies were published recently, and the majority of the studies were good quality cost-effectiveness analyses with an adequate duration of time frame. All the included studies found the DHIs to be cost-effective. UR - http://www.jmir.org/2019/6/e13166/ UR - http://dx.doi.org/10.2196/13166 UR - http://www.ncbi.nlm.nih.gov/pubmed/31210136 ID - info:doi/10.2196/13166 ER - TY - JOUR AU - Zhang, Yonglai AU - Zhou, Yaojian AU - Zhang, Dongsong AU - Song, Wenai PY - 2019/04/02 TI - A Stroke Risk Detection: Improving Hybrid Feature Selection Method JO - J Med Internet Res SP - e12437 VL - 21 IS - 4 KW - machine learning KW - stroke KW - risk KW - feature selection KW - WRHFS N2 - Background: Stroke is one of the most common diseases that cause mortality. Detecting the risk of stroke for individuals is critical yet challenging because of a large number of risk factors for stroke. Objective: This study aimed to address the limitation of ineffective feature selection in existing research on stroke risk detection. We have proposed a new feature selection method called weighting- and ranking-based hybrid feature selection (WRHFS) to select important risk factors for detecting ischemic stroke. Methods: WRHFS integrates the strengths of various filter algorithms by following the principle of a wrapper approach. We employed a variety of filter-based feature selection models as the candidate set, including standard deviation, Pearson correlation coefficient, Fisher score, information gain, Relief algorithm, and chi-square test and used sensitivity, specificity, accuracy, and Youden index as performance metrics to evaluate the proposed method. Results: This study chose 792 samples from the electronic records of 13,421 patients in a community hospital. Each sample included 28 features (24 blood test features and 4 demographic features). The results of evaluation showed that the proposed method selected 9 important features out of the original 28 features and significantly outperformed baseline methods. Their cumulative contribution was 0.51. The WRHFS method achieved a sensitivity of 82.7% (329/398), specificity of 80.4% (317/394), classification accuracy of 81.5% (645/792), and Youden index of 0.63 using only the top 9 features. We have also presented a chart for visualizing the risk of having ischemic strokes. Conclusions: This study has proposed, developed, and evaluated a new feature selection method for identifying the most important features for building effective and parsimonious models for stroke risk detection. The findings of this research provide several novel research contributions and practical implications. UR - https://www.jmir.org/2019/4/e12437/ UR - http://dx.doi.org/10.2196/12437 UR - http://www.ncbi.nlm.nih.gov/pubmed/30938684 ID - info:doi/10.2196/12437 ER - TY - JOUR AU - Appalasamy, Rani Jamuna AU - Joseph, Pauline Joyce AU - Seeta Ramaiah, Siva AU - Quek, Fatt Kia AU - Md Zain, Zaini Anuar AU - Tha, Kyi Kyi PY - 2019/03/21 TI - An Intervention to Promote Medication Understanding and Use Self-Efficacy: Design of Video Narratives for Aging Patients at Risk of Recurrent Stroke JO - JMIR Aging SP - e11539 VL - 2 IS - 1 KW - Delphi technique KW - self-efficacy KW - stroke KW - personal narratives KW - video-audio media KW - beliefs N2 - Background: The debilitating effects of recurrent stroke among aging patients have urged researchers to explore medication adherence among these patients. Video narratives built upon Health Belief Model (HBM) constructs have displayed potential impact on medication adherence, adding an advantage to patient education efforts. However, its effect on medication understanding and use self-efficacy have not been tested. Objective: The researchers believed that culturally sensitive video narratives, which catered to a specific niche, would reveal a personalized impact on medication adherence. Therefore, this study aimed to develop and validate video narratives for this purpose. Methods: This study adapted the Delphi method to develop a consensus on the video scripts? contents based on learning outcomes and HBM constructs. The panel of experts comprised 8 members representing professional stroke disease experts and experienced poststroke patients in Malaysia. The Delphi method involved 3 rounds of discussions. Once the consensus among members was achieved, the researchers drafted the initial scripts in English, which were then back translated to the Malay language. A total of 10 bilingual patients, within the study?s inclusion criteria, screened the scripts for comprehension. Subsequently, a neurologist and poststroke patient narrated the scripts in both languages as they were filmed, to add to the realism of the narratives. Then, the video narratives underwent a few cycles of editing after some feedback on video engagement by the bilingual patients. Few statistical analyses were applied to confirm the validity and reliability of the video narratives. Results: Initially, the researchers proposed 8 learning outcomes and 9 questions based on HBM constructs for the video scripts? content. However, following Delphi rounds 1 to 3, a few statements were omitted and rephrased. The Kendall coefficient of concordance, W, was about 0.7 (P<.001) for both learning outcomes and questions which indicated good agreement between members. Each statement?s Cronbach alpha was above .8 with SD values within a range below 1.5 that confirmed satisfactory content and construct validity. Approximately 75% (6/8) of members agreed that all chosen statements were relevant and suitable for video script content development. Similarly, more than 80% (8/10) of patients scored video engagement above average, intraclass correlation coefficient was above 0.7, whereas its Kendall W was about 0.7 with significance (P<.001), which indicated average agreement that the video narratives perceived realism. Conclusions: The Delphi method was proven to be helpful in conducting discussions systematically and providing precise content for the development of video narratives, whereas the Video Engagement Scale was an appropriate measurement of video realism and emotions, which the researchers believed could positively impact medication understanding and use self-efficacy among patients with stroke. A feasibility and acceptability study in an actual stroke care center is needed. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000174280; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?id=373554&isReview=true UR - http://aging.jmir.org/2019/1/e11539/ UR - http://dx.doi.org/10.2196/11539 UR - http://www.ncbi.nlm.nih.gov/pubmed/31518260 ID - info:doi/10.2196/11539 ER - TY - JOUR AU - Lee, A. Mikyoung AU - Shin, Cha-Nam AU - An, Kyungeh PY - 2018/07/20 TI - Trustworthiness, Readability, and Suitability of Web-Based Information for Stroke Prevention and Self-Management for Korean Americans: Critical Evaluation JO - Interact J Med Res SP - e10440 VL - 7 IS - 2 KW - stroke KW - website evaluation KW - trustworthiness KW - readability KW - suitability N2 - Background: Websites are common sources of health information to stroke survivors and caregivers for continual management of stroke and its long-term sequelae. The presence of risk factors and mortality rates related to stroke are high in Korean Americans. A vast majority of this group are active Web users and rely on the Web-based information due to lack of insurance and, thus, limited access to long-term stroke care. Thus, it is critical to evaluate existing stroke websites for their trustworthiness, readability, and suitability. Objective: The objective of our study was to provide a systematic evaluation of stroke-related websites regarding (1) trustworthiness, (2) readability, and (3) suitability for stroke prevention and self-management for Korean Americans. Methods: We selected a total of 156 websites using search terms ?stroke,? ?CVA,? ??? (jungpung),? and ???? (noejoljung)? on Google and Yahoo. After eliminating duplicates and irrelevant websites (n=116), we evaluated a total of 42 websites (15 in English and 27 in Korean) using the National Library of Medicine?s health website?s evaluation tool for trustworthiness; Simple Measure of Gobbledygook for readability; and Suitability Assessment of Materials for suitability. All three instruments used the 3-point Likert scale: superior (=2), adequate (=1), or not suitable (=0). Results: Of the 42 websites evaluated, we rated 62% (26/42) websites as ?adequate? or above for trustworthiness. The information on 48% (20/42) websites had not been updated for more than a year, which indicates poor currency; 33% (14/42) websites failed to provide the publisher and contact information, which yields poor authority; 50% (21/42) websites did not cite sources of health information, which indicates lack of accuracy. Only 2 websites met the recommended readability (5th grade or lower reading level). The suitability was also suboptimal; only 1 website was rated as ?superior?; 60% (25/42) websites were ?adequate,? and 38% (16/42) were ?not suitable.? Most websites were limited in graphical directions, interactive motivations for desired healthy behaviors, and multiple language translations. Conclusions: The existing stroke-related websites in either English or Korean are trustworthy and suitable, yet precise citation of evidence-based information will improve trustworthiness. The contents requiring high reading level may set a barrier to the utilization of Web-based health information for Korean Americans with a lower level of education. In addition, supplementing graphical examples, interaction features, and culturally relevant information in multiple languages are the areas for improvement in suitability. The improved features can reduce the reading burden of stroke patients or caregivers and build their confidence when applying the information for stroke management in daily living. These strategies are especially crucial to Korean Americans, who inevitably seek Web-based information to fill the gap between their demand and access to health care for a long-term self-management after a stroke. UR - http://www.i-jmr.org/2018/2/e10440/ UR - http://dx.doi.org/10.2196/10440 UR - http://www.ncbi.nlm.nih.gov/pubmed/30030210 ID - info:doi/10.2196/10440 ER - TY - JOUR AU - Rozanski, M. Gabriela AU - Aqui, Anthony AU - Sivakumaran, Shajicaa AU - Mansfield, Avril PY - 2018/01/04 TI - Consumer Wearable Devices for Activity Monitoring Among Individuals After a Stroke: A Prospective Comparison JO - JMIR Cardio SP - e1 VL - 2 IS - 1 KW - physical activity KW - heart rate KW - accelerometry KW - stroke rehabilitation KW - walking N2 - Background: Activity monitoring is necessary to investigate sedentary behavior after a stroke. Consumer wearable devices are an attractive alternative to research-grade technology, but measurement properties have not been established. Objective: The purpose of this study was to determine the accuracy of 2 wrist-worn fitness trackers: Fitbit Charge HR (FBT) and Garmin Vivosmart (GAR). Methods: Adults attending in- or outpatient therapy for stroke (n=37) wore FBT and GAR each on 2 separate days, in addition to an X6 accelerometer and Actigraph chest strap monitor. Step counts and heart rate data were extracted, and the agreement between devices was determined using Pearson or Spearman correlation and paired t or Wilcoxon signed rank tests (one- and two-sided). Subgroup analyses were conducted. Results: Step counts from FBT and GAR positively correlated with the X6 accelerometer (?=.78 and ?=.65, P<.001, respectively) but were significantly lower (P<.01). For individuals using a rollator, there was no significant correlation between step counts from the X6 accelerometer and either FBT (?=.42, P=.12) or GAR (?=.30, P=.27). Heart rate from Actigraph, FBT, and GAR demonstrated responsiveness to changes in activity. Both FBT and GAR positively correlated with Actigraph for average heart rate (r=.53 and .75, P<.01, respectively) and time in target zone (?=.49 and .74, P<.01, respectively); these measures were not significantly different, but nonequivalence was found. Conclusions: FBT and GAR had moderate to strong correlation with best available reference measures of walking activity in individuals with subacute stroke. Accuracy appears to be lower among rollator users and varies according to heart rhythm. Consumer wearables may be a viable option for large-scale studies of physical activity. UR - http://cardio.jmir.org/2018/1/e1/ UR - http://dx.doi.org/10.2196/cardio.8199 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758760 ID - info:doi/10.2196/cardio.8199 ER -